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10 September 2021 The 'Getting It Right First Time' Programme National Specialty Report on pathology has been published The Getting It Right First Time (GIRFT) review of pathology, led by Tom Lewis, Marion Wood and Martin Myers, hopes to set out how to enable patients get "the buy 250mg amoxil online right test at the right time, with the right answer." The recommendations are based on the visits that the clinical leads made to labs and pathology networks across England, in addition to other data and audits. It encourages others to see pathology as an end-to-end service, starting with the clinical encounter that leads to the right test being requested, and ending with the right results going back to the right patient in the right timeframe. The GIRFT report also advises investment in the workforce and ways to create a more flexible workforce. In particular, it looks at ways to offer wider opportunities to the buy 250mg amoxil online biomedical scientist community, encouraging our profession to deepen current skills and acquire further specialist qualifications. It supports a greater flexibility and a wider range of roles for biomedical scientists and hopes to maximise the potential of the workforce.IBMS Chief Executive David Wells commented.

We welcome this report and the commitment to improve the quality of England’s pathology services, continuing to highlight the need for services to work in a coordinated, evidence based way, using the expertise of the Biomedical and Clinical workforce. We also welcome buy 250mg amoxil online the acknowledgement that Biomedical Scientists can operate at the highest level within pathology and share our commitment to grow and expand our workforce - making sure access to higher qualifications are a priority using existing Institute qualifications and access routes such as the HSST. You can find download the report in full below. The section relating to maximising the potential of the biomedical science workforce is on page 113 to 125.9 September 2021 IBMS Fellow Professor Tony Rhodes has been appointed the journal's new editor. Tony takes over as editor of the British Journal of Biomedical Science (BJBS) from Dr Andrew Blann, who has held the buy 250mg amoxil online position since November 2015.

Following his appointment, Tony commented. "It is truly a great honour to take on the role of editor of the British Journal of Biomedical Science, a journal which I have received as part of my membership since joining the IBMS, back in 1984. Dr Andrew Blann has done a fantastic job over buy 250mg amoxil online the years by greatly increasing its impact and visibility beyond what many of us ever thought possible. This will have significant benefits for our profession as the baton has now passed over to me at the time of a new phase of the journal's development, with a new publisher and a new 'Open Access' format. I hope to widen the scope of the journal, maintain its current impact trajectory and importantly, ensure that it remains the journal of the practicing biomedical scientist." Tony is currently a professor in the School of Health Sciences at the International Medical University, Kuala Lumpur, where he has just led a successful re-accreditation of the BSc (Hons) Degree Programme in Biomedical Sciences with the IBMS.

Previously, he was a Professor in the Department of buy 250mg amoxil online Pathology, Faculty of Medicine, at the University Malaya and still holds an honorary chair there. He moved to academia in 2003 as a Senior Lecturer in Cellular Pathology at the University of the West of England following a successful career as a biomedical scientist in the NHS, working at. The London School of Hygiene and Tropical Medicine, St Thomas's Hospital, Hammersmith Hospital London, and finally as Senior Chief Biomedical Scientist in the Department of Anatomic Pathology at the University College London Medical School. Tony’s appointment follows the announcement that the journal will be moving to 'gold-open access' when relaunched with new publishing buy 250mg amoxil online partner Frontiers. This is in line with the International Science Council's (ISC) recent statement endorsing UNESCO's commitment to a new paradigm of 'open science'.

IBMS chief executive David Wells commented. "I would buy 250mg amoxil online like to congratulate Professor Tony Rhodes on his appointment as the new editor of the BJBS. He will bring a unique blend of expertise and skills which I am sure will see the journal continue to grow as we transition to an open-access format. I would like to thank Dr Andrew Blann for his dedication and hard work in his time as the BJBS editor. Andrew has done a great job with improving the journal's quality, particularly evidenced by the improvement in the impact factor.” The BJBS is buy 250mg amoxil online the profession's leading journal, featuring authoritative papers and short reports on new laboratory techniques and principles.

Under the new open-access format, starting from January 2022, all recent articles in the BJBS will be immediately and permanently available to access freely for all and IBMS members will not be charged to publish their work. Tony will commence his role as the editor of the BJBS from October 1st 2021..

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Start Preamble Office of Infectious Disease and HIV/AIDS Policy (OIDP), Office of the Assistant generic amoxil prices Secretary for Health, Office of the Secretary, Department of Health and Human Services (HHS). Notice. The Department generic amoxil prices of Health and Human Services (HHS) Office of Infectious Disease and HIV/AIDS Policy (OIDP) in the Office of the Assistant Secretary for Health (OASH) announces the draft treatments National Strategic Plan 2021-2025 (treatment Plan) available for public comment. The draft treatment Plan may be reviewed at www.hhs.gov/​oidp.

All comments must be received by 5:00 p.m. ET on generic amoxil prices December 3, 2020 to be considered. All comments must be submitted electronically to NVP.RFI@hhs.gov to be considered. Start Further Info David Kim, OIDP, David.Kim@hhs.gov, 202-795-7636.

End Further Info End Preamble Start Supplemental Information The development of a National treatment Plan was mandated by Congress as a mechanism for the Director of the National treatment Program (as delegated by the Assistant Secretary for Health) to communicate priorities for achieving the Program's responsibilities of ensuring adequate supply of and access to treatments and ensuring the effective and generic amoxil prices optimal use of treatments. The most recent Plan, released in 2010, provided a comprehensive 10-year national strategy for enhancing all aspects of the plan, including treatment research and development, supply, financing, distribution, and safety. Informed decision-making generic amoxil prices by consumers and health care providers. treatment-preventable disease surveillance.

treatment effectiveness and use monitoring. And global generic amoxil prices cooperation (http://www.hhs.gov/​nvpo/​vacc_​plan/​index.html). The 2010 Plan and the associated implementation plan (https://www.hhs.gov/​sites/​default/​files/​nvpo/​vacc_​plan/​2010-2015-Plan/​implementationplan.pdf) have played an important role in guiding strategies and allocations of resources with respect to treatments and vaccination. However, since the publication of the 2010 Plan, there have been many changes in the treatment landscape.

With U.S generic amoxil prices. Vaccination rates above 90% for many childhood treatments, most individuals have not witnessed firsthand the devastating illnesses against which treatments offer protection, such as polio or diphtheria. According to a recent study, routine childhood immunizations among U.S. Children born in 2009 will prevent 20 million cases of disease and 42,000 premature deaths, with a net savings of $13.5 billion in direct costs and $68.8 billion in total societal costs.[] In contrast, adult vaccination coverage rates have remained persistently low, with only modest gains for certain populations in the past few years.[] As a result, generic amoxil prices the standards for adult immunization practice were updated in 2014 to promote integration of treatments into routine clinical care for adults.[] Start Printed Page 74739 Despite the widespread availability of effective treatments, treatment-preventable diseases (VPDs) remain a significant public health challenge.

In particular, rates of non-medical exemptions for childhood treatments are increasing,[] and there have been recent measles outbreaks in the U.S.[] and globally, due to growing treatment hesitancy and coverage levels below the threshold needed for herd immunity. With an estimated cost of $20,000 per case of measles to the public sector in 2016,[] the economic consequences of this and other VPDs, as generic amoxil prices well as the health consequences, are significant. Furthermore, few adults in any age group are fully vaccinated as recommended by the Advisory Committee on Immunization Practices.[] Large disparities in treatment coverage by race/ethnicity persist, with African Americans, Hispanics, and Asian Americans lagging behind whites in nearly all vaccination coverage rates.[] VPDs such as pertussis and hepatitis B continue to take a heavy toll on public health,[] with 18,975 cases of pertussis and 3,409 (22,000 estimated) cases of hepatitis B s reported in the United States in 2017.[] In light of these challenges, strengthening the treatment and immunization enterprise is a priority for HHS. To respond to the public health challenges of VPDs, OIDP in collaboration with other federal partners is leading the development of the treatments National Strategic Plan (treatment Plan).

This updated plan will recommend treatment strategies across the lifespan generic amoxil prices and guide priority actions for the period 2021-2025. While buy antibiotics and antibiotics treatment development are currently changing the landscape of the treatment enterprise, the treatment Plan has a broad focus on the entire treatment enterprise and is not focused specifically on any one treatment or the amoxil response. HHS, through OIDP, seeks input regarding the draft of the treatment Plan from subject matter experts and nonfederal partners and stakeholders such as health care providers, national professional organizations, health departments, school administrators, community-based and faith-based organizations, manufacturers, researchers, advocates, and persons affected by VPDs. The following are the treatment Plan's vision and goals generic amoxil prices.

Vision. United States will be a place where treatment-preventable diseases are eliminated through safe and effective vaccination over the lifespan. Goals. 1.

Foster innovation in treatment development and related technologies. 2. Maintain the highest possible levels of treatment safety. 3.

Increase knowledge of and confidence in routinely recommended. 4. Increase access to and use of all routinely recommended treatments. 5.

Protect the health of the American public by supporting global immunization efforts. Information Needs The draft treatment Plan may be reviewed at www.hhs.gov/​oidp. OIDP seeks to obtain feedback from external stakeholders on the following. 1.

Do the draft treatment Plan's goals, objectives, and strategies appropriately address the treatment landscape?. 2. Are there any critical gaps in the treatment Plan's goals, objectives, and strategies?. If so, please specify the gaps.

3. Do any of the treatment Plan's goals, objectives and strategies cause concern?. If so, please specify the goal, objective or strategy, and describe the concern regarding it. Please be succinct and limit your comments to a maximum of seven pages.

Start Authority 42 U.S.C. Section 300aa-3. End Authority Start Signature Dated. November 17, 2020.

B. Kaye Hayes, Acting Director, Office of Infectious Disease and HIV/AIDS Policy. End Signature End Supplemental Information [FR Doc. 2020-25842 Filed 11-20-20.

8:45 am]BILLING CODE 4150-43-PStart Preamble National Institutes of Health, HHS. Notice. This Request for Information (RFI) is intended to gather broad public input on the National Institutes of Health (NIH)-Wide Strategic Plan for buy antibiotics Research. Because of the urgency and evolving nature of the amoxil, NIH intends this plan to be a living document, which will be continually updated to reflect new challenges presented by buy antibiotics.

To ensure that it remains in step with public needs, this RFI invites stakeholders throughout the scientific research, advocacy, and clinical practice communities, as well as the general public to comment on the NIH-Wide Strategic Plan for buy antibiotics Research. Organizations are strongly encouraged to submit a single response that reflects the views of their organization and their membership as a whole. This RFI is open for public comment for a period of five weeks. Comments must be received by 11:59:59 p.m.

(ET) on December 7, 2020 to ensure consideration. Start Printed Page 69336 All comments must be submitted electronically on the submission website, available at. Https://rfi.grants.nih.gov/​?. S=​5f91a3efdb70000018003362.

Start Further Info Please direct all inquiries to. Beth Walsh, nihstrategicplan@od.nih.gov, 301-496-4000. End Further Info End Preamble Start Supplemental Information Urgent public health measures are needed to control the spread of the novel antibiotics (antibiotics) and the disease it causes, antibiotics disease 2019, or buy antibiotics. Scientific research to improve basic understanding of antibiotics and buy antibiotics, and to develop the necessary tools and approaches to better prevent, diagnose, and treat this disease is of paramount importance.

The NIH-Wide Strategic Plan for buy antibiotics Research (available at. Https://www.nih.gov/​research-training/​medical-research-initiatives/​nih-wide-strategic-plan-buy antibiotics-research), released on July 13, 2020, provides a framework for achieving this goal. It describes how NIH is rapidly mobilizing diverse stakeholders, including the biomedical research community, industry, and philanthropic organizations, through new programs and existing resources, to lead a swift, coordinated research response to this global amoxil. The plan outlines how NIH is implementing five Priorities, guided by three Crosscutting Strategies.

Priorities Priority 1. Improve Fundamental Knowledge of antibiotics and buy antibiotics ○ Objective 1.1. Advance fundamental research for antibiotics and buy antibiotics ○ Objective 1.2. Support research to develop preclinical models of antibiotics and buy antibiotics ○ Objective 1.3.

Advance the understanding of antibiotics transmission and buy antibiotics dynamics at the population level ○ Objective 1.4. Understand buy antibiotics disease progression, recovery, and psychosocial and behavioral health consequences Priority 2. Advance Detection and Diagnosis of buy antibiotics ○ Objective 2.1. Support research to develop and validate new diagnostic technologies ○ Objective 2.2.

Retool existing diagnostics for detection of antibiotics ○ Objective 2.3. Support research to develop and validate serological assays Priority 3. Advance the Treatment of buy antibiotics ○ Objective 3.1. Identify and develop new or repurposed treatments for antibiotics ○ Objective 3.2.

Evaluate new, repurposed, or existing treatments and treatment strategies for buy antibiotics ○ Objective 3.3. Investigate strategies for access to and implementation of buy antibiotics treatments Priority 4. Improve Prevention of antibiotics ○ Objective 4.1. Develop novel treatments for the prevention of buy antibiotics ○ Objective 4.2.

Develop and study other methods to prevent antibiotics transmission ○ Objective 4.3. Develop effective implementation models for preventive measures Priority 5. Prevent and Redress Poor buy antibiotics Outcomes in Health Disparity and Vulnerable Populations ○ Objective 5.1. Understand and address buy antibiotics as it relates to health disparities and buy antibiotics—vulnerable populations in the United States ○ Objective 5.2.

Understand and address buy antibiotics maternal health and pregnancy outcomes ○ Objective 5.3. Understand and address age-specific factors in buy antibiotics ○ Objective 5.4. Address global health research needs from buy antibiotics Crosscutting Strategies Partnering to promote collaborative science ○ Leverage existing NIH-funded global research networks and private sector, public, and non-profit relationships ○ Coordinate with Federal partners ○ Establish new public-private partnerships Supporting the research workforce and infrastructure ○ Conduct research to elucidate how buy antibiotics impacts the scientific workforce ○ Provide research resources ○ Leverage intramural infrastructure to support extramural researchers ○ Conduct virtual peer review processes Investing in data science ○ Create new data science resources and analytical tools ○ Develop shared metrics and terminologies NIH seeks comments on any or all of, but not limited to, the following topics. Significant research gaps or barriers not identified in the existing framework above.

Resources required or lacking or existing leverageable resources (e.g., existing partnerships, collaborations, or infrastructure) that could advance the strategic priorities. Emerging scientific advances or techniques in basic, diagnostic, therapeutic, or treatment research that may accelerate the research priorities detailed in the framework above. And Additional ideas for bold, innovative research initiatives, processes, or data-driven approaches that could advance the response to buy antibiotics. NIH encourages organizations (e.g., patient advocacy groups, professional organizations) to submit a single response reflective of the views of the organization or membership as a whole.

Responses to this RFI are voluntary and may be submitted anonymously. Please do not include any personally identifiable information or any information that you do not wish to make public. Proprietary, classified, confidential, or sensitive information should not be included in your response. The Government will use the information submitted in response to this RFI at its discretion.

The Government reserves the right to use any submitted information on public websites, in reports, in summaries of the state of the science, in any possible resultant solicitation(s), grant(s), or cooperative agreement(s), or in the development of future funding opportunity announcements. This RFI is for informational and planning purposes only and is not a solicitation for applications or an obligation on the part of the Government to provide support for any ideas identified in response to it. Please note that the Government will not pay for the preparation of any information submitted or for use of that information. We look forward to your input and hope that you will share this RFI opportunity with your colleagues.

Start Signature Dated. October 27, 2020. Lawrence A. Tabak, Principal Deputy Director, National Institutes of Health.

End Signature End Supplemental Information [FR Doc. 2020-24202 Filed 10-30-20. 8:45 am]BILLING CODE 4140-01-P.

Start Preamble i thought about this Office of Infectious Disease and buy 250mg amoxil online HIV/AIDS Policy (OIDP), Office of the Assistant Secretary for Health, Office of the Secretary, Department of Health and Human Services (HHS). Notice. The Department of Health and Human Services (HHS) Office of Infectious Disease and HIV/AIDS Policy (OIDP) in the Office of the buy 250mg amoxil online Assistant Secretary for Health (OASH) announces the draft treatments National Strategic Plan 2021-2025 (treatment Plan) available for public comment.

The draft treatment Plan may be reviewed at www.hhs.gov/​oidp. All comments must be received by 5:00 p.m. ET on December 3, 2020 to be buy 250mg amoxil online considered.

All comments must be submitted electronically to NVP.RFI@hhs.gov to be considered. Start Further Info David Kim, OIDP, David.Kim@hhs.gov, 202-795-7636. End Further Info End Preamble Start Supplemental Information The development of a National treatment Plan was mandated by Congress as a mechanism for the Director of the National treatment Program (as delegated by the Assistant Secretary buy 250mg amoxil online for Health) to communicate priorities for achieving the Program's responsibilities of ensuring adequate supply of and access to treatments and ensuring the effective and optimal use of treatments.

The most recent Plan, released in 2010, provided a comprehensive 10-year national strategy for enhancing all aspects of the plan, including treatment research and development, supply, financing, distribution, and safety. Informed decision-making by consumers and health care buy 250mg amoxil online providers. treatment-preventable disease surveillance.

treatment effectiveness and use monitoring. And global cooperation (http://www.hhs.gov/​nvpo/​vacc_​plan/​index.html) buy 250mg amoxil online. The 2010 Plan and the associated implementation plan (https://www.hhs.gov/​sites/​default/​files/​nvpo/​vacc_​plan/​2010-2015-Plan/​implementationplan.pdf) have played an important role in guiding strategies and allocations of resources with respect to treatments and vaccination.

However, since the publication of the 2010 Plan, there have been many changes in the treatment landscape. With U.S buy 250mg amoxil online. Vaccination rates above 90% for many childhood treatments, most individuals have not witnessed firsthand the devastating illnesses against which treatments offer protection, such as polio or diphtheria.

According to a recent study, routine childhood immunizations among U.S. Children born in 2009 will prevent 20 million cases of disease and 42,000 premature deaths, with a net savings of $13.5 billion in direct costs and $68.8 billion in total buy 250mg amoxil online societal costs.[] In contrast, adult vaccination coverage rates have remained persistently low, with only modest gains for certain populations in the past few years.[] As a result, the standards for adult immunization practice were updated in 2014 to promote integration of treatments into routine clinical care for adults.[] Start Printed Page 74739 Despite the widespread availability of effective treatments, treatment-preventable diseases (VPDs) remain a significant public health challenge. In particular, rates of non-medical exemptions for childhood treatments are increasing,[] and there have been recent measles outbreaks in the U.S.[] and globally, due to growing treatment hesitancy and coverage levels below the threshold needed for herd immunity.

With an estimated cost of $20,000 per case of measles to the public sector in 2016,[] the economic consequences of buy 250mg amoxil online this and other VPDs, as well as the health consequences, are significant. Furthermore, few adults in any age group are fully vaccinated as recommended by the Advisory Committee on Immunization Practices.[] Large disparities in treatment coverage by race/ethnicity persist, with African Americans, Hispanics, and Asian Americans lagging behind whites in nearly all vaccination coverage rates.[] VPDs such as pertussis and hepatitis B continue to take a heavy toll on public health,[] with 18,975 cases of pertussis and 3,409 (22,000 estimated) cases of hepatitis B s reported in the United States in 2017.[] In light of these challenges, strengthening the treatment and immunization enterprise is a priority for HHS. To respond to the public health challenges of VPDs, OIDP in collaboration with other federal partners is leading the development of the treatments National Strategic Plan (treatment Plan).

This updated plan will recommend treatment strategies across buy 250mg amoxil online the lifespan and guide priority actions for the period 2021-2025. While buy antibiotics and antibiotics treatment development are currently changing the landscape of the treatment enterprise, the treatment Plan has a broad focus on the entire treatment enterprise and is not focused specifically on any one treatment or the amoxil response. HHS, through OIDP, seeks input regarding the draft of the treatment Plan from subject matter experts and nonfederal partners and stakeholders such as health care providers, national professional organizations, health departments, school administrators, community-based and faith-based organizations, manufacturers, researchers, advocates, and persons affected by VPDs.

The following are the treatment Plan's buy 250mg amoxil online vision and goals. Vision. United States will be a place where treatment-preventable diseases are eliminated through safe and effective vaccination over the lifespan.

Goals. 1. Foster innovation in treatment development and related technologies.

2. Maintain the highest possible levels of treatment safety. 3.

Increase knowledge of and confidence in routinely recommended. 4. Increase access to and use of all routinely recommended treatments.

5. Protect the health of the American public by supporting global immunization efforts. Information Needs The draft treatment Plan may be reviewed at www.hhs.gov/​oidp.

OIDP seeks to obtain feedback from external stakeholders on the following. 1. Do the draft treatment Plan's goals, objectives, and strategies appropriately address the treatment landscape?.

2. Are there any critical gaps in the treatment Plan's goals, objectives, and strategies?. If so, please specify the gaps.

3. Do any of the treatment Plan's goals, objectives and strategies cause concern?. If so, please specify the goal, objective or strategy, and describe the concern regarding it.

Please be succinct and limit your comments to a maximum of seven pages. Start Authority 42 U.S.C. Section 300aa-3.

End Authority Start Signature Dated. November 17, 2020. B.

Kaye Hayes, Acting Director, Office of Infectious Disease and HIV/AIDS Policy. End Signature End Supplemental Information [FR Doc. 2020-25842 Filed 11-20-20.

8:45 am]BILLING CODE 4150-43-PStart Preamble National Institutes of Health, HHS. Notice. This Request for Information (RFI) is intended to gather broad public input on the National Institutes of Health (NIH)-Wide Strategic Plan for buy antibiotics Research.

Because of the urgency and evolving nature of the amoxil, NIH intends this plan to be a living document, which will be continually updated to reflect new challenges presented by buy antibiotics. To ensure that it remains in step with public needs, this RFI invites stakeholders throughout the scientific research, advocacy, and clinical practice communities, as well as the general public to comment on the NIH-Wide Strategic Plan for buy antibiotics Research. Organizations are strongly encouraged to submit a single response that reflects the views of their organization and their membership as a whole.

This RFI is open for public comment for a period of five weeks. Comments must be received by 11:59:59 p.m. (ET) on December 7, 2020 to ensure consideration.

Start Printed Page 69336 All comments must be submitted electronically on the submission website, available at. Https://rfi.grants.nih.gov/​?. S=​5f91a3efdb70000018003362.

Start Further Info Please direct all inquiries to. Beth Walsh, nihstrategicplan@od.nih.gov, 301-496-4000. End Further Info End Preamble Start Supplemental Information Urgent public health measures are needed to control the spread of the novel antibiotics (antibiotics) and the disease it causes, antibiotics disease 2019, or buy antibiotics.

Scientific research to improve basic understanding of antibiotics and buy antibiotics, and to develop the necessary tools and approaches to better prevent, diagnose, and treat this disease is of paramount importance. The NIH-Wide Strategic Plan for buy antibiotics Research (available at. Https://www.nih.gov/​research-training/​medical-research-initiatives/​nih-wide-strategic-plan-buy antibiotics-research), released on July 13, 2020, provides a framework for achieving this goal.

It describes how NIH is rapidly mobilizing diverse stakeholders, including the biomedical research community, industry, and philanthropic organizations, through new programs and existing resources, to lead a swift, coordinated research response to this global amoxil. The plan outlines how NIH is implementing five Priorities, guided by three Crosscutting Strategies. Priorities Priority 1.

Improve Fundamental Knowledge of antibiotics and buy antibiotics ○ Objective 1.1. Advance fundamental research for antibiotics and buy antibiotics ○ Objective 1.2. Support research to develop preclinical models of antibiotics and buy antibiotics ○ Objective 1.3.

Advance the understanding of antibiotics transmission and buy antibiotics dynamics at the population level ○ Objective 1.4. Understand buy antibiotics disease progression, recovery, and psychosocial and behavioral health consequences Priority 2. Advance Detection and Diagnosis of buy antibiotics ○ Objective 2.1.

Support research to develop and validate new diagnostic technologies ○ Objective 2.2. Retool existing diagnostics for detection of antibiotics ○ Objective 2.3. Support research to develop and validate serological assays Priority 3.

Advance the Treatment of buy antibiotics ○ Objective 3.1. Identify and develop new or repurposed treatments for antibiotics ○ Objective 3.2. Evaluate new, repurposed, or existing treatments and treatment strategies for buy antibiotics ○ Objective 3.3.

Investigate strategies for access to and implementation of buy antibiotics treatments Priority 4. Improve Prevention of antibiotics ○ Objective 4.1. Develop novel treatments for the prevention of buy antibiotics ○ Objective 4.2.

Develop and study other methods to prevent antibiotics transmission ○ Objective 4.3. Develop effective implementation models for preventive measures Priority 5. Prevent and Redress Poor buy antibiotics Outcomes in Health Disparity and Vulnerable Populations ○ Objective 5.1.

Understand and address buy antibiotics as it relates to health disparities and buy antibiotics—vulnerable populations in the United States ○ Objective 5.2. Understand and address buy antibiotics maternal health and pregnancy outcomes ○ Objective 5.3. Understand and address age-specific factors in buy antibiotics ○ Objective 5.4.

Address global health research needs from buy antibiotics Crosscutting Strategies Partnering to promote collaborative science ○ Leverage existing NIH-funded global research networks and private sector, public, and non-profit relationships ○ Coordinate with Federal partners ○ Establish new public-private partnerships Supporting the research workforce and infrastructure ○ Conduct research to elucidate how buy antibiotics impacts the scientific workforce ○ Provide research resources ○ Leverage intramural infrastructure to support extramural researchers ○ Conduct virtual peer review processes Investing in data science ○ Create new data science resources and analytical tools ○ Develop shared metrics and terminologies NIH seeks comments on any or all of, but not limited to, the following topics. Significant research gaps or barriers not identified in the existing framework above. Resources required or lacking or existing leverageable resources (e.g., existing partnerships, collaborations, or infrastructure) that could advance the strategic priorities.

Emerging scientific advances or techniques in basic, diagnostic, therapeutic, or treatment research that may accelerate the research priorities detailed in the framework above. And Additional ideas for bold, innovative research initiatives, processes, or data-driven approaches that could advance the response to buy antibiotics. NIH encourages organizations (e.g., patient advocacy groups, professional organizations) to submit a single response reflective of the views of the organization or membership as a whole.

Responses to this RFI are voluntary and may be submitted anonymously. Please do not include any personally identifiable information or any information that you do not wish to make public. Proprietary, classified, confidential, or sensitive information should not be included in your response.

The Government will use the information submitted in response to this RFI at its discretion. The Government reserves the right to use any submitted information on public websites, in reports, in summaries of the state of the science, in any possible resultant solicitation(s), grant(s), or cooperative agreement(s), or in the development of future funding opportunity announcements. This RFI is for informational and planning purposes only and is not a solicitation for applications or an obligation on the part of the Government to provide support for any ideas identified in response to it.

Please note that the Government will not pay for the preparation of any information submitted or for use of that information. We look forward to your input and hope that you will share this RFI opportunity with your colleagues. Start Signature Dated.

October 27, 2020. Lawrence A. Tabak, Principal Deputy Director, National Institutes of Health.

End Signature End Supplemental Information [FR Doc. 2020-24202 Filed 10-30-20. 8:45 am]BILLING CODE 4140-01-P.

What side effects may I notice from Amoxil?

Side effects that you should report to your doctor or health care professional as soon as possible:

• allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
• breathing problems
• dark urine
• redness, blistering, peeling or loosening of the skin, including inside the mouth
• seizures
• severe or watery diarrhea
• trouble passing urine or change in the amount of urine
• unusual bleeding or bruising
• unusually weak or tired
• yellowing of the eyes or skin

Side effects that usually do not require medical attention (report to your doctor or health care professional if they continue or are bothersome):

• dizziness
• headache
• stomach upset
• trouble sleeping

This list may not describe all possible side effects.

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The typical user is most likely a third party claims adjudicator, provincial formulary, insurance company, etc. A casual user of this file must be familiar with database amoxil online canadian pharmacy structure and capable of setting up queries. The "Read me" file contains the data structure required to download the zipped files.The NOC extract files have been updated. They contain Health Canada amoxil online canadian pharmacy authorization dates for all drugs dating back to 1994 that have received an NOC.

All NOCs issued between 1991 and 1993 can be found in the NOC listings.Please note any Portable Document Format (PDF) files visible on the NOC database are not part of the data extracts.For more information, please go to the Read Me File.Data Extracts - Last updated. 2021-08-20 CopyrightFor information on copyright and who to contact, please visit the Notice of Compliance Online Database Terms and Conditions.The fee as of April 1, 2021 is $9,756 Register of Certificates of Supplementary Protection and Applications Guidance Document. Certificate of amoxil online canadian pharmacy Supplementary Protection Regulations - summary Notice. Publication of update to the Guidance Document.

Certificate of Supplementary Protection Regulations CSP Application Form (effective January 6, 2021) CSP Application Form (effective April 1, 2020 to January 5, 2021) CSP Application Form (effective May 15, 2019 to March 31, 2020) CSP Application Form (effective September 22, 2018 to May 14, 2019) CSP Application Form (from September 21, 2017 to September 21, 2018) Advance Payment Details for Master Files for Human and Disinfectant Drugs, and Certificate of Supplementary Protection Applications How to Pay Fees to Health Products and Food Branch (HPFB) Background Register of Certificates of Supplementary Protection and Applications Certificates of Supplementary Protection and Applications - Human Use Certificate of Supplementary Protection (CSP) and/or Application Number Medicinal Ingredient(s) New Drug Submission (NDS) Number Patent Number Patent Expiry Dateyyyy-mm-dd Application Status CSP Term Beginsyyyy-mm-dd CSP Term Endsyyyy-mm-dd 900039 abemaciclib 215268 2747055 2029-12-15 Issued 2029-12-16 2031-12-15 900045 acalabrutinib 214504 2841886 2032-07-11 Issued 2032-07-12 2034-07-11 900056 alpelisib 226941 2734819 2029-09-08 Issued 2029-09-09 2031-09-08 900035 antihemophilic factor (recombinant, B-domain deleted, pegylated) (also known as damoctocog alfa pegol) 210935 2586379 2025-11-14 Issued 2025-11-15 2027-11-14 900027 apalutamide 211942 2875767 2033-06-04 Issued 2033-06-05 2033-07-04 900026 baricitinib 193687 2718271 2029-03-10 Issued 2029-03-11 2031-03-10 900012 benralizumab 204008 2685222 2028-05-14 Issued 2028-05-15 2030-05-14 900028 bictegravir sodium / emtricitabine / tenofovir alafenamide hemifumarate 203718 2416757 2021-07-20 Refused 900020 brigatinib 210369 2723961 2029-05-21 Issued 2029-05-22 2031-05-21 900015 brodalumab 195317 2663537 2027-10-01 Issued 2027-10-02 2029-10-01 900060 brolucizumab 226224 2727839 2029-06-25 Issued 2029-06-26 2031-06-25 900057 cabotegravir (cabotegravir sodium) 227315 2606282 2026-04-28 Issued 2026-04-29 2028-04-28 900063 cedazuridine / decitabine 234610 2702274 2028-10-16 Issued 2028-10-17 2030-10-16 900022 cenegermin 218145 2346257 2019-10-11 Refused 900083 ciclesonide 200882 2888428 2033-12-18 Pending 900011 coagulation factor IX (recombinant), pegylated 201114 2462930 2022-10-09 Refused 900052 coagulation factor IX (recombinant), pegylated 201114 2665480 2027-10-04 Refused 900019 crisaborole 206906 2597982 2026-02-16 Issued 2026-02-17 2028-02-16 900041 dacomitinib 214572 2565812 2025-04-25 Issued 2025-04-26 2027-04-25 900058 darolutamide 226146 2777896 2030-10-27 Issued 2030-10-28 2032-10-27 900017 darunavir ethanolate / cobicistat / emtricitabine / tenofovir alafenamide hemifumarate 199705 2678907 2028-02-22 Issued 2028-02-23 2030-02-22 900051 dolutegravir (dolutegravir sodium) / lamivudine 220275 3003988 2031-01-24 Issued 2031-01-25 2033-01-24 900021 dolutegravir (dolutegravir sodium) / rilpivirine (rilpivirine hydrochloride) 206402 2606282 2026-04-28 Refused 900034 doravirine 211293 2794377 2031-03-28 Issued 2031-03-29 2033-03-28 900004 dupilumab 201285 2737044 2029-10-27 Issued 2029-10-28 2031-10-27 900010 durvalumab 202953 2778714 2030-11-24 Issued 2030-11-25 2032-11-04 900024 emicizumab 212635 2817964 2031-11-17 Issued 2031-11-18 2033-08-03 900053 entrectinib 227517 2693901 2028-07-08 Issued 2028-07-09 2030-07-08 900074 eptinezumab 233288 2836649 2032-05-21 Issued 2032-05-22 2034-05-21 900070 erdafitinib 224529 2796204 2031-04-28 Issued 2031-04-29 2033-04-28 900025 erenumab 208607 2746858 2029-12-18 Issued 2029-12-19 2031-12-18 900018 ertugliflozin 204724 2733795 2029-08-17 Issued 2029-08-18 2031-08-17 900076 estetrol monohydrate / drospirenone 236197 2448278 2022-05-23 Issued 2022-05-24 2024-05-23 900033 fluticasone furoate, umeclidinium (as bromide), vilanterol (as trifenatate) 204880 2781487 2030-11-29 Issued 2030-11-30 2032-11-29 900044 galcanezumab 219521 2802102 2031-06-07 Issued 2031-06-08 2033-06-07 900055 gilteritinib fumarate 227918 2760061 2030-05-06 Issued 2030-05-07 2032-05-06 900062 glasdegib 225793 2690953 2028-06-16 Issued 2028-06-17 2030-06-16 900001 glecaprevir / pibrentasvir 202233 2807847 2031-10-12 Refused 900014 glycopyrronium (as bromide) / formoterol fumarate dihydrate 201306 2763936 2030-05-28 Refused 900003 guselkumab 200590 2635692 2026-12-28 Issued 2026-12-29 2028-12-28 900032 inotersen (inotersen sodium) 214274 2797792 2031-04-29 Issued 2031-04-30 2033-04-29 900023 insulin glargine / lixisenatide 207006 2740685 2029-10-09 Issued 2029-10-10 2031-10-09 900029 lanadelumab 213920 2786019 2031-01-06 Issued 2031-01-07 2033-01-06 900043 larotrectinib (larotrectinib sulfate) 219998 2741313 2029-10-21 Issued 2029-10-22 2031-10-21 900066 lefamulin (supplied as lefamulin acetate) 233292 2678795 2028-03-19 Issued 2028-03-20 2030-03-19 900069 lemborexant 231286 2811895 2031-09-20 Issued 2031-09-21 2033-09-20 900007 letermovir 204165 2524069 2024-04-17 Issued 2024-04-18 2026-04-17 900009 lifitegrast 199810 2609053 2026-05-17 Issued 2026-05-18 2028-05-17 900040 lorlatinib 215733 2863892 2033-02-20 Issued 2033-02-21 2034-02-23 900071 luspatercept 236441 2733911 2029-08-13 Issued 2029-08-14 2031-08-13 900002 neisseria meningitidis grp B recombinant lipoprotein 2086 subfamily A / neisseria meningitidis grp B recombinant lipoprotein 2086 subfamily B 195550 2463476 2022-10-11 Issued 2022-10-12 2024-10-11 900008 olaratumab 203478 2680945 2026-06-19 Issued 2026-06-20 2028-06-19 900072 ozanimod (ozanimod hydrochloride) 232761 2723904 2029-05-14 Issued 2029-05-15 2031-05-14 900073 ozanimod (ozanimod hydrochloride) 232761 2780772 2030-11-15 Withdrawn 900080 pertuzumab, trastuzumab 237402 2788253 2032-08-29 Pending 900067 polatuzumab vedotin 232303 2693255 2028-07-15 Issued 2028-07-16 2030-07-15 900079 ponesimod 239537 2968180 2035-12-10 Pending 900050 prasterone 198822 2696127 2028-08-08 Withdrawn 900068 remdesivir 240551 2804840 2031-07-22 Issued 2031-07-23 2033-07-22 900016 ribociclib (ribociclib succinate) 203884 2734802 2029-08-20 Issued 2029-08-21 2031-08-20 900065 ripretinib 234688 2875970 2032-06-07 Issued 2032-06-08 2034-06-07 900042 risankizumab 215753 2816950 2031-11-02 Issued 2031-11-03 2033-11-02 900078 risdiplam 242373 2948561 2035-05-11 Pending 900031 rivaroxaban 211611 2451258 2022-06-07 Pending 900046 romosozumab 197713 2607197 2026-04-28 Issued 2026-04-29 2028-04-28 900061 satralizumab 233642 2699834 2029-09-25 Issued 2029-09-26 2031-09-25 900005 semaglutide 202059 2601784 2026-03-20 Issued 2026-03-21 2028-03-20 900054 siponimod 223225 2747437 2029-12-16 Withdrawn 900059 siponimod 223225 2747992 2029-12-21 Issued 2029-12-22 2031-12-21 900038 suvorexant 160233 2670892 2027-11-30 Refused 900048 talazoparib (talazoparib tosylate) 220584 2732797 2029-07-27 Issued 2029-07-28 2031-07-27 900082 tepotinib hydrochloride 242300 2693600 2028-04-29 Pending 900036 tezacaftor / Ivacaftor 211292 2742821 2028-11-12 Issued 2028-11-13 2030-11-12 900030 tisagenlecleucel 213547 2820681 2031-12-09 Issued 2031-12-10 2033-12-09 900081 trastuzumab / deruxtecan 242104 2928794 2035-01-28 Pending 900064 tucatinib 235295 2632194 2026-11-15 Issued 2026-11-16 2028-11-15 900049 upadacitinib 223734 2781891 2030-12-01 Issued 2030-12-02 2032-12-01 900006 varicella-zoster amoxil glycoprotein E (gE) 200244 2600905 2026-03-01 Refused 900075 zanubrutinib 242748 2902686 2034-04-22 Issued 2034-04-23 2036-03-02 Certificates of Supplementary Protection and Applications - Veterinary Use Certificate of Supplementary Protection (CSP) and/orApplication Number Medicinal Ingredient(s) New Drug Submission (NDS) Number Patent Number Patent Expiry Dateyyyy-mm-dd Application Status CSP Term Beginsyyyy-mm-dd CSP Term Endsyyyy-mm-dd 900083 ciclesonide 200882 2888428 2033-12-18 Pending 900077 esafoxolaner / eprinomectin / praziquantel 234676 2848317 2032-09-12 Pending 900013 lotilaner 193712 2747354 2029-12-17 Issued 2029-12-18 2031-12-17 900047 sarolaner/moxidectin/pyrantel (as pyrantel pamoate) 210868 2882200 2033-09-04 Issued 2033-09-05 2034-09-27 900037 sarolaner / selamectin 190913 2828397 2032-02-23 Issued 2032-02-24 2033-11-07 Background The Register of Certificates of Supplementary Protection (CSP) and Applications is maintained pursuant to the Certificate of Supplementary Protection Regulations and the Patent Act. The register includes information from CSPs amoxil online canadian pharmacy and CSP applications. Under the subsection 115(1) of the Patent Act, the issuance of a CSP grants the certificate's holder and their legal representatives the same legal rights, privileges and liberties that are granted by the patent set out in the certificate, but only with respect to the making, constructing, using and selling of any drug that contains the medicinal ingredient, or combination of medicinal ingredients. The format amoxil online canadian pharmacy of the register is an electronic table.

The register lists, in alphabetical order, the medicinal ingredient(s) in the CSPs and CSP applications. Information regarding the patent set out in the CSP or CSP application is available at the Canadian Intellectual Property Office. For comments or questions, or to obtain a copy of a CSP or CSP application details, please contact the Office of Patented amoxil online canadian pharmacy Medicines and Liaison by email at hc.opml-bmbl.sc@canada.ca or by telephone at 613-941-7281.The amoxil continues to highlight a pressing need to use social and behavioural data alongside biomedical data to mount an effective response. Timely data and insights into people’s changing knowledge, attitudes and behaviours helps to ensure that the response is tailored and adapted to the needs of the population.Due to the rapidly evolving situation, many countries are facing challenges in the availability of accurate and up-to-date social and behavioural data.

In response to this situation, WHO has developed the “Social and Behavioural Insights buy antibiotics Data Collection Tool for Africa”. The tool can be used by WHO Country Offices, NGOs, universities or other groups amoxil online canadian pharmacy interested in capturing quantitative and qualitative social and behavioural data.World Health Organization and Imperial College London joint press releaseThe number of adults aged 30–79 years with hypertension has increased from 650 million to 1.28 billion in the last thirty years, according to the first comprehensive global analysis of trends in hypertension prevalence, detection, treatment and control, led by Imperial College London and WHO, and published today in The Lancet. Nearly half these people did not know they had hypertension. Hypertension significantly increases the risk of heart, brain and kidney diseases, amoxil online canadian pharmacy and is one of the top causes of death and disease throughout the world.

It can be easily detected through measuring blood pressure, at home or in a health centre, and can often be treated effectively with medications that are low cost.The study, conducted by a global network of physicians and researchers, covered the period 1990–2019. It used blood pressure measurement and treatment data from over 100 million people aged 30–79 years in 184 countries, together covering 99% of the global population, which makes it the most comprehensive review of global trends in hypertension to date.By analysing this massive amount of data, the researchers found that there was little change in the overall rate of hypertension in the world from 1990 to 2019, but the burden has shifted from wealthy nations to low- and middle-income countries. The rate of hypertension has decreased in wealthy countries amoxil online canadian pharmacy – which now typically have some of the lowest rates – but has increased in many low- or middle-income countries. As a result, Canada, Peru and Switzerland had among the lowest prevalence of hypertension in the world in 2019, while some of the highest rates were seen in the Dominican Republic, Jamaica and Paraguay for women and Hungary, Paraguay and Poland for men.

(See notes to editors for country breakdowns/rankings).Although the percent of people who have hypertension has changed little since 1990, the number of people with hypertension doubled to 1.28 billion. This was amoxil online canadian pharmacy primarily due to population growth and ageing. In 2019, over one billion people with hypertension (82% of all people with hypertension in the world) lived in low- and middle-income countries. Significant gaps amoxil online canadian pharmacy in diagnosis and treatmentAlthough it is straightforward to diagnose hypertension and relatively easy to treat the condition with low-cost drugs, the study revealed significant gaps in diagnosis and treatment.

About 580 million people with hypertension (41% of women and 51% of men) were unaware of their condition because they were never diagnosed. The study also indicated that more than half of people (53% of women and 62% of men) with hypertension, or a total 720 million people, were not receiving the treatment that they need. Blood pressure was controlled, amoxil online canadian pharmacy which means medicines were effective in bringing blood pressure to normal ranges, in fewer than 1 in 4 women and 1 in 5 men with hypertension.Professor Majid Ezzati, senior author of the study and Professor of Global Environmental Health at the School of Public Health at Imperial College London, said. €œNearly half a century after we started treating hypertension, which is easy to diagnose and treat with low-cost medicines, it is a public health failure that so many of the people with high blood pressure in the world are still not getting the treatment they need.”Men and women in Canada, Iceland and the Republic of Korea were most likely to receive medication to effectively treat and control their hypertension, with more than 70% of those with hypertension receiving treatment in 2019.

Comparatively, men and women in sub-Saharan Africa, central, south and south-east Asia, and Pacific Island nations are the least likely to be receiving medication. Treatment rates were below 25% for women, and 20% for men, in a number of countries in these regions, creating a massive global inequity in treatment.Encouragingly, some middle-income countries have successfully scaled up treatment, amoxil online canadian pharmacy and are now achieving better treatment and control rates than most high-income nations. For example, Costa Rica and Kazakhstan now have higher treatment rates than most higher-income countries. Dr Bin Zhou, a research fellow at the School of Public Health at Imperial College London, amoxil online canadian pharmacy who led the analysis, said.

€œAlthough hypertension treatment and control rates have improved in most countries since 1990, there has been little change in much of sub-Saharan Africa and Pacific Island nations. International funders and national governments need to prioritize global treatment equity for this major global health risk.”New WHO guideline for hypertension treatmentThe ‘WHO Guideline for the pharmacological treatment of hypertension in adults’, also released today, provides new recommendations to help countries improve the management of hypertension.Dr Taskeen Khan, of WHO’s Department of Noncommunicable Diseases, who led the guideline development, said. €œThe new global guideline on the treatment of hypertension, the first in 20 years, provides the most current and relevant evidence-based guidance on the initiation of medicines for hypertension in adults.” The recommendations cover the level of blood pressure to start medication, what type of medicine or combination of medicines to use, the target blood pressure level, and how often to have follow-up amoxil online canadian pharmacy checks on blood pressure. In addition, the guideline provides the basis for how physicians and other health workers can contribute to improving hypertension detection and management.Dr Bente Mikkelsen, Director of WHO’s Department of Noncommunicable Diseases added.

€œThe need to better manage hypertension cannot be exaggerated. By following the recommendations in amoxil online canadian pharmacy this new guideline, increasing and improving access to blood pressure medication, identifying and treating comorbidities such as diabetes and pre-existing heart disease, promoting healthier diets and regular physical activity, and more strictly controlling tobacco products, countries will be able to save lives and reduce public health expenditures.”NOTES TO EDITORS‘Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019. A pooled analysis of 1,201 population-representative studies with 104 million participants’ by the NCD Risk Factor Collaboration (NCD-RisC) is published in The Lancet. DOI.

10.1016/S0140-6736(21)01330-1Data were taken from 1201 studies with 104 million participants in 184 countries, aged 30-79 years, with measurement of blood pressure and data on blood pressure treatment.Hypertension was defined as having systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, and/or taking medication for hypertension.The Republic of Korea in this press release is indicated as South Korea in the associated paper.Imperial College LondonImperial College London is one of the world's leading universities. The College's 20 000 students and 8000 staff are working to solve the biggest challenges in science, medicine, engineering and business.Imperial is the world’s fifth most international university, according to Times Higher Education, with academic ties to more than 150 countries. Reuters named the College as the UK's most innovative university because of its exceptional entrepreneurial culture and ties to industry.Imperial staff, students and alumni are working round-the-clock to combat buy antibiotics. Imperial has nearly two thousand key workers, and is at the forefront of antibiotics epidemiology, virology, treatment development and diagnostics.

More than one thousand Imperial staff and students are volunteering to support the NHS. Http://www.imperial.ac.uk/The World Health OrganizationDedicated to the well-being of all people and guided by science, the World Health Organization (WHO) leads and champions global efforts to give everyone, everywhere an equal chance at a safe and healthy life. WHO is the UN agency for heath that connects nations, partners and people on the front lines in 150+ locations – leading the world’s response to health emergencies, preventing disease, addressing the root causes of health issues and expanding access to medicines and health care. Our mission is to promote health, keep the world safe and serve the vulnerable.

Www.who.intTop 10 countries with the lowest hypertension prevalence in 2019WOMEN Ranking Country Prevalence as % of population 1. Switzerland 17% 2. Peru 18% 3. Canada 20% 4.

Taiwan (Province of China) 21% 5. Spain 21% 6. Republic of Korea 21% 7. Japan 22% 8.

United Kingdom 23% 9. China 24% 10. Iceland 24% MEN Ranking Country Prevalence as % of population 1. Eritrea 22% 2.

Peru 23% 3. Bangladesh 24% 4. Canada 24% 5. Ethiopia 25% 6.

Solomon Islands 25% 7. Papua New Guinea 25% 8. Lao PDR 26% 9. Cambodia 26% 10.

Switzerland 26% Top 10 countries with the highest hypertension prevalence in 2019WOMEN Ranking Country Prevalence as % of population 1. Paraguay 51% 2. Tuvalu 51% 3. Dominica 50% 4.

Dominican Republic 49% 5. Sao Tome and Principe 48% 6. Jamaica 48% 7. Haiti 48% 8.

Iraq 48% 9. Eswatini 47% 10. Botswana 47% MEN Ranking Country Prevalence as % of population 1. Paraguay 62% 2.

Hungary 56% 3. Poland 55% 4. Argentina 54% 5. Lithuania 54% 6.

Romania 53% 7. Belarus 52% 8. Croatia 51% 9. Tajikistan 51% 10.

Serbia 50% Top 10 countries with the highest hypertension treatment rate in 2019WOMEN Ranking Country Rate as % of all women with hypertension 1. Republic of Korea 77% 2. Costa Rica 76% 3. Kazakhstan 74% 4.

United States of America 73% 5. Iceland 72% 6. Venezuela 71% 7. El Salvador 71% 8.

Portugal 71% 9. Canada 71% 10. Slovakia 70% MEN Ranking Country Rate as % of all men with hypertension 1. Canada 76% 2.

Iceland 71% 3. Republic of Korea 67% 4. United States of America 66% 5. Kazakhstan 66% 6.

Malta 65% 7. Costa Rica 63% 8. Germany 61% 9. Czechia 59% 10.

Singapore 59% Top 10 countries with the lowest hypertension treatment rate in 2019WOMEN Ranking Country Rate as % of all women with hypertension 1. Rwanda 11% 2. Niger 15% 3. Kiribati 15% 4.

Ethiopia 16% 5. Vanuatu 16% 6. Tanzania 17% 7. Solomon Islands 17% 8.

Madagascar 19% 9. Mozambique 19% 10. Kenya 21% MEN Ranking Country Rate as % of all men with hypertension 1. Rwanda 10% 2.

Kenya 10% 3. Mozambique 10% 4. Vanuatu 11% 5. Solomon Islands 11% 6.

Niger 12% 7. Madagascar 13% 8. Uganda 13% 9. Togo 14% 10.

Burkina Faso 14% Top 10 countries with the largest increase in hypertension prevalence between 1990 and 2019WOMEN Ranking Country Percentage point increase (1990 - 2019) 1. Kiribati 13 2. Tonga 13 3. Tuvalu 12 4.

Indonesia 12 5. Brunei Darussalam 10 6. Haiti 9 7. Jamaica 9 8.

Myanmar 9 9. Samoa 9 10. Uzbekistan 9 MEN Ranking Country Percentage point increase (1990 - 2019) 1. Uzbekistan 15 2.

Argentina 13 3. Paraguay 10 4. South Africa 10 5. China 10 6.

Brunei Darussalam 9 7. Tajikistan 8 8. Jamaica 8 9. Dominican Republic 8 10.

Tuvalu 8 Top 10 countries with the largest decline in hypertension prevalence between 1990 and 2019WOMEN Ranking Country Percentage point decrease (1990 - 2019) 1. Germany 18 2. Spain 14 3. Japan 13 4.

Singapore 12 5. Russian Federation 12 6. Italy 12 7. Austria 11 8.

United Kingdom 11 9. Israel 11 10. Sweden 10 MEN Ranking Country Percentage point decrease (1990 - 2019) 1. Germany 19 2.

Switzerland 14 3. United Kingdom 13 4. Finland 12 5. Canada 12 6.

Luxembourg 10 7. Norway 10 8. Austria 9 9. Italy 8 10.

Malawi 8 Top 10 countries with the largest increase in treatment rate between 1990 and 2019WOMEN Ranking Country Percentage point increase (1990 - 2019) 1. Republic of Korea 46 2. Taiwan (Province of China) 38 3. South Africa 36 4.

Costa Rica 35 5. Poland 35 6. Venezuela 35 7. Serbia 33 8.

Brunei Darussalam 33 9. Singapore 33 10. Colombia 33 MEN Ranking Country Percentage point increase (1990 - 2019) 1. Republic of Korea 50 2.

Canada 46 3. Costa Rica 40 4. Germany 39 5. Iceland 39 6.

Taiwan (Province of China) 37 7. Kazakhstan 37 8. Poland 36 9. Switzerland 36 10.

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Certificate of Supplementary Protection Regulations CSP Application Form (effective January 6, 2021) CSP Application Form (effective April 1, 2020 to January 5, 2021) CSP Application Form (effective May 15, 2019 to March 31, 2020) CSP Application Form (effective September 22, 2018 to May 14, 2019) CSP Application Form (from September 21, 2017 to September 21, 2018) Advance Payment Details for Master Files for Human and Disinfectant Drugs, and Certificate of Supplementary Protection Applications How to Pay Fees to Health Products and Food Branch (HPFB) Background Register of Certificates of Supplementary Protection and Applications Certificates of Supplementary Protection and Applications - Human Use Certificate of Supplementary Protection (CSP) and/or Application Number Medicinal Ingredient(s) New Drug Submission (NDS) Number Patent Number Patent Expiry Dateyyyy-mm-dd Application Status CSP Term Beginsyyyy-mm-dd CSP Term Endsyyyy-mm-dd 900039 abemaciclib 215268 2747055 2029-12-15 Issued 2029-12-16 2031-12-15 900045 acalabrutinib 214504 2841886 2032-07-11 Issued 2032-07-12 2034-07-11 900056 alpelisib 226941 2734819 2029-09-08 Issued 2029-09-09 2031-09-08 900035 antihemophilic factor (recombinant, B-domain deleted, pegylated) (also known as damoctocog alfa pegol) 210935 2586379 2025-11-14 Issued 2025-11-15 2027-11-14 900027 apalutamide 211942 2875767 2033-06-04 Issued 2033-06-05 2033-07-04 900026 baricitinib 193687 2718271 2029-03-10 Issued 2029-03-11 2031-03-10 900012 benralizumab 204008 2685222 2028-05-14 Issued 2028-05-15 2030-05-14 900028 bictegravir sodium / emtricitabine / tenofovir alafenamide hemifumarate 203718 2416757 2021-07-20 Refused 900020 brigatinib 210369 2723961 2029-05-21 Issued 2029-05-22 2031-05-21 900015 brodalumab 195317 2663537 2027-10-01 Issued 2027-10-02 2029-10-01 900060 brolucizumab 226224 2727839 2029-06-25 Issued 2029-06-26 2031-06-25 900057 cabotegravir (cabotegravir sodium) 227315 2606282 2026-04-28 Issued 2026-04-29 2028-04-28 900063 cedazuridine / decitabine 234610 2702274 2028-10-16 Issued 2028-10-17 2030-10-16 900022 cenegermin 218145 2346257 2019-10-11 Refused 900083 ciclesonide 200882 2888428 2033-12-18 Pending 900011 coagulation factor IX (recombinant), pegylated 201114 2462930 2022-10-09 Refused 900052 coagulation factor IX (recombinant), pegylated 201114 2665480 2027-10-04 Refused 900019 crisaborole 206906 2597982 2026-02-16 Issued 2026-02-17 2028-02-16 900041 dacomitinib 214572 2565812 2025-04-25 Issued 2025-04-26 2027-04-25 900058 darolutamide 226146 2777896 2030-10-27 Issued 2030-10-28 2032-10-27 900017 darunavir ethanolate / cobicistat / emtricitabine / tenofovir alafenamide hemifumarate 199705 2678907 2028-02-22 Issued 2028-02-23 2030-02-22 900051 dolutegravir (dolutegravir sodium) / lamivudine 220275 3003988 2031-01-24 Issued 2031-01-25 2033-01-24 900021 dolutegravir (dolutegravir sodium) / rilpivirine (rilpivirine hydrochloride) 206402 2606282 2026-04-28 Refused 900034 doravirine 211293 2794377 2031-03-28 Issued 2031-03-29 2033-03-28 900004 dupilumab 201285 2737044 2029-10-27 Issued 2029-10-28 2031-10-27 900010 durvalumab 202953 2778714 2030-11-24 Issued 2030-11-25 2032-11-04 900024 emicizumab 212635 2817964 2031-11-17 Issued 2031-11-18 2033-08-03 900053 entrectinib 227517 2693901 2028-07-08 Issued 2028-07-09 2030-07-08 900074 eptinezumab 233288 2836649 2032-05-21 Issued 2032-05-22 2034-05-21 900070 erdafitinib 224529 2796204 2031-04-28 Issued 2031-04-29 2033-04-28 900025 erenumab 208607 2746858 2029-12-18 Issued 2029-12-19 2031-12-18 900018 ertugliflozin 204724 2733795 2029-08-17 Issued 2029-08-18 2031-08-17 900076 estetrol monohydrate / drospirenone 236197 2448278 2022-05-23 Issued 2022-05-24 2024-05-23 900033 fluticasone furoate, umeclidinium (as bromide), vilanterol (as trifenatate) 204880 2781487 2030-11-29 Issued 2030-11-30 2032-11-29 900044 galcanezumab 219521 2802102 2031-06-07 Issued 2031-06-08 2033-06-07 900055 gilteritinib fumarate 227918 2760061 2030-05-06 Issued 2030-05-07 2032-05-06 900062 glasdegib 225793 2690953 2028-06-16 Issued 2028-06-17 2030-06-16 900001 glecaprevir / pibrentasvir 202233 2807847 2031-10-12 Refused 900014 glycopyrronium (as bromide) / formoterol fumarate dihydrate 201306 2763936 2030-05-28 Refused 900003 guselkumab 200590 2635692 2026-12-28 Issued 2026-12-29 2028-12-28 900032 inotersen (inotersen sodium) 214274 2797792 2031-04-29 Issued 2031-04-30 2033-04-29 900023 insulin glargine / lixisenatide 207006 2740685 2029-10-09 Issued 2029-10-10 2031-10-09 900029 lanadelumab 213920 2786019 2031-01-06 Issued 2031-01-07 2033-01-06 900043 larotrectinib (larotrectinib sulfate) 219998 2741313 2029-10-21 Issued 2029-10-22 2031-10-21 900066 lefamulin (supplied as lefamulin acetate) 233292 2678795 2028-03-19 Issued 2028-03-20 2030-03-19 900069 lemborexant 231286 2811895 2031-09-20 Issued 2031-09-21 2033-09-20 900007 letermovir 204165 2524069 2024-04-17 Issued 2024-04-18 2026-04-17 900009 lifitegrast 199810 2609053 2026-05-17 Issued 2026-05-18 2028-05-17 900040 lorlatinib 215733 2863892 2033-02-20 Issued 2033-02-21 2034-02-23 900071 luspatercept 236441 2733911 2029-08-13 Issued 2029-08-14 2031-08-13 900002 neisseria meningitidis grp B recombinant lipoprotein 2086 subfamily A / neisseria meningitidis grp B recombinant lipoprotein 2086 subfamily B 195550 2463476 2022-10-11 Issued 2022-10-12 2024-10-11 900008 olaratumab 203478 2680945 2026-06-19 Issued 2026-06-20 2028-06-19 900072 ozanimod (ozanimod hydrochloride) 232761 2723904 2029-05-14 Issued 2029-05-15 2031-05-14 900073 ozanimod (ozanimod hydrochloride) 232761 2780772 2030-11-15 Withdrawn 900080 pertuzumab, trastuzumab 237402 2788253 2032-08-29 Pending 900067 polatuzumab vedotin 232303 2693255 2028-07-15 Issued 2028-07-16 2030-07-15 900079 ponesimod 239537 2968180 2035-12-10 Pending 900050 prasterone 198822 2696127 2028-08-08 Withdrawn 900068 remdesivir 240551 2804840 2031-07-22 Issued 2031-07-23 2033-07-22 900016 ribociclib (ribociclib succinate) 203884 2734802 2029-08-20 Issued 2029-08-21 2031-08-20 900065 ripretinib 234688 2875970 2032-06-07 Issued 2032-06-08 2034-06-07 900042 risankizumab 215753 2816950 2031-11-02 Issued 2031-11-03 2033-11-02 900078 risdiplam 242373 2948561 2035-05-11 Pending 900031 rivaroxaban 211611 2451258 2022-06-07 Pending 900046 romosozumab 197713 2607197 2026-04-28 Issued 2026-04-29 2028-04-28 900061 satralizumab 233642 2699834 2029-09-25 Issued 2029-09-26 2031-09-25 900005 semaglutide 202059 2601784 2026-03-20 Issued 2026-03-21 2028-03-20 900054 siponimod 223225 2747437 2029-12-16 Withdrawn 900059 siponimod 223225 2747992 2029-12-21 Issued 2029-12-22 2031-12-21 900038 suvorexant 160233 2670892 2027-11-30 Refused 900048 talazoparib (talazoparib tosylate) 220584 2732797 2029-07-27 Issued 2029-07-28 2031-07-27 900082 tepotinib hydrochloride 242300 2693600 2028-04-29 Pending 900036 tezacaftor / Ivacaftor 211292 2742821 2028-11-12 Issued 2028-11-13 2030-11-12 900030 tisagenlecleucel 213547 2820681 2031-12-09 Issued 2031-12-10 2033-12-09 900081 trastuzumab / deruxtecan 242104 2928794 2035-01-28 Pending 900064 tucatinib 235295 2632194 2026-11-15 Issued 2026-11-16 2028-11-15 900049 upadacitinib 223734 2781891 2030-12-01 Issued 2030-12-02 2032-12-01 900006 varicella-zoster amoxil glycoprotein E (gE) 200244 2600905 2026-03-01 Refused 900075 zanubrutinib 242748 2902686 2034-04-22 Issued 2034-04-23 2036-03-02 Certificates of Supplementary Protection and Applications - Veterinary Use Certificate of Supplementary Protection (CSP) and/orApplication Number Medicinal Ingredient(s) New Drug Submission (NDS) Number Patent Number Patent Expiry Dateyyyy-mm-dd Application Status CSP Term Beginsyyyy-mm-dd CSP Term Endsyyyy-mm-dd 900083 ciclesonide 200882 2888428 2033-12-18 Pending 900077 esafoxolaner / eprinomectin / praziquantel 234676 2848317 2032-09-12 Pending 900013 lotilaner 193712 2747354 2029-12-17 Issued 2029-12-18 2031-12-17 900047 sarolaner/moxidectin/pyrantel (as pyrantel pamoate) 210868 2882200 2033-09-04 Issued 2033-09-05 2034-09-27 900037 sarolaner / selamectin 190913 2828397 2032-02-23 Issued 2032-02-24 2033-11-07 Background The Register of Certificates of Supplementary Protection (CSP) and Applications is maintained pursuant to the Certificate of Supplementary Protection Regulations and the Patent Act. The register includes information from CSPs buy 250mg amoxil online and CSP applications. Under the subsection 115(1) of the Patent Act, the issuance of a CSP grants the certificate's holder and their legal representatives the same legal rights, privileges and liberties that are granted by the patent set out in the certificate, but only with respect to the making, constructing, using and selling of any drug that contains the medicinal ingredient, or combination of medicinal ingredients.

The format of buy 250mg amoxil online the register is an electronic table. The register lists, in alphabetical order, the medicinal ingredient(s) in the CSPs and CSP applications. Information regarding the patent set out in the CSP or CSP application is available at the Canadian Intellectual Property Office.

For comments or questions, or to obtain a copy of a CSP or CSP application details, please buy 250mg amoxil online contact the Office of Patented Medicines and Liaison by email at hc.opml-bmbl.sc@canada.ca or by telephone at 613-941-7281.The amoxil continues to highlight a pressing need to use social and behavioural data alongside biomedical data to mount an effective response. Timely data and insights into people’s changing knowledge, attitudes and behaviours helps to ensure that the response is tailored and adapted to the needs of the population.Due to the rapidly evolving situation, many countries are facing challenges in the availability of accurate and up-to-date social and behavioural data. In response to this situation, WHO has developed the “Social and Behavioural Insights buy antibiotics Data Collection Tool for Africa”.

The tool can be used by WHO Country Offices, NGOs, universities or other groups interested in capturing quantitative and qualitative social and behavioural data.World Health Organization and Imperial College London joint press releaseThe number of adults aged 30–79 years with hypertension has increased from 650 million to 1.28 billion in the last thirty years, according to the first comprehensive global analysis of trends in hypertension prevalence, detection, treatment and control, led buy 250mg amoxil online by Imperial College London and WHO, and published today in The Lancet. Nearly half these people did not know they had hypertension. Hypertension significantly increases buy 250mg amoxil online the risk of heart, brain and kidney diseases, and is one of the top causes of death and disease throughout the world.

It can be easily detected through measuring blood pressure, at home or in a health centre, and can often be treated effectively with medications that are low cost.The study, conducted by a global network of physicians and researchers, covered the period 1990–2019. It used blood pressure measurement and treatment data from over 100 million people aged 30–79 years in 184 countries, together covering 99% of the global population, which makes it the most comprehensive review of global trends in hypertension to date.By analysing this massive amount of data, the researchers found that there was little change in the overall rate of hypertension in the world from 1990 to 2019, but the burden has shifted from wealthy nations to low- and middle-income countries. The rate buy 250mg amoxil online of hypertension has decreased in wealthy countries – which now typically have some of the lowest rates – but has increased in many low- or middle-income countries.

As a result, Canada, Peru and Switzerland had among the lowest prevalence of hypertension in the world in 2019, while some of the highest rates were seen in the Dominican Republic, Jamaica and Paraguay for women and Hungary, Paraguay and Poland for men. (See notes to editors for country breakdowns/rankings).Although the percent of people who have hypertension has changed little since 1990, the number of people with hypertension doubled to 1.28 billion. This was buy 250mg amoxil online primarily due to population growth and ageing.

In 2019, over one billion people with hypertension (82% of all people with hypertension in the world) lived in low- and middle-income countries. Significant gaps in diagnosis and treatmentAlthough it is straightforward to diagnose hypertension and relatively easy to treat the buy 250mg amoxil online condition with low-cost drugs, the study revealed significant gaps in diagnosis and treatment. About 580 million people with hypertension (41% of women and 51% of men) were unaware of their condition because they were never diagnosed.

The study also indicated that more than half of people (53% of women and 62% of men) with hypertension, or a total 720 million people, were not receiving the treatment that they need. Blood pressure was controlled, which means medicines were effective in bringing blood pressure to normal ranges, in fewer than 1 in 4 women and buy 250mg amoxil online 1 in 5 men with hypertension.Professor Majid Ezzati, senior author of the study and Professor of Global Environmental Health at the School of Public Health at Imperial College London, said. €œNearly half a century after we started treating hypertension, which is easy to diagnose and treat with low-cost medicines, it is a public health failure that so many of the people with high blood pressure in the world are still not getting the treatment they need.”Men and women in Canada, Iceland and the Republic of Korea were most likely to receive medication to effectively treat and control their hypertension, with more than 70% of those with hypertension receiving treatment in 2019.

Comparatively, men and women in sub-Saharan Africa, central, south and south-east Asia, and Pacific Island nations are the least likely to be receiving medication. Treatment rates buy 250mg amoxil online were below 25% for women, and 20% for men, in a number of countries in these regions, creating a massive global inequity in treatment.Encouragingly, some middle-income countries have successfully scaled up treatment, and are now achieving better treatment and control rates than most high-income nations. For example, Costa Rica and Kazakhstan now have higher treatment rates than most higher-income countries.

Dr Bin Zhou, a research fellow at the School of Public Health at Imperial College London, who led the buy 250mg amoxil online analysis, said. €œAlthough hypertension treatment and control rates have improved in most countries since 1990, there has been little change in much of sub-Saharan Africa and Pacific Island nations. International funders and national governments need to prioritize global treatment equity for this major global health risk.”New WHO guideline for hypertension treatmentThe ‘WHO Guideline for the pharmacological treatment of hypertension in adults’, also released today, provides new recommendations to help countries improve the management of hypertension.Dr Taskeen Khan, of WHO’s Department of Noncommunicable Diseases, who led the guideline development, said.

€œThe new global guideline on the treatment of hypertension, buy 250mg amoxil online the first in 20 years, provides the most current and relevant evidence-based guidance on the initiation of medicines for hypertension in adults.” The recommendations cover the level of blood pressure to start medication, what type of medicine or combination of medicines to use, the target blood pressure level, and how often to have follow-up checks on blood pressure. In addition, the guideline provides the basis for how physicians and other health workers can contribute to improving hypertension detection and management.Dr Bente Mikkelsen, Director of WHO’s Department of Noncommunicable Diseases added. €œThe need to better manage hypertension cannot be exaggerated.

By following the recommendations in this new guideline, increasing and improving access to blood pressure medication, identifying and treating comorbidities such as diabetes and buy 250mg amoxil online pre-existing heart disease, promoting healthier diets and regular physical activity, and more strictly controlling tobacco products, countries will be able to save lives and reduce public health expenditures.”NOTES TO EDITORS‘Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019. A pooled analysis of 1,201 population-representative studies with 104 million participants’ by the NCD Risk Factor Collaboration (NCD-RisC) is published in The Lancet. DOI.

10.1016/S0140-6736(21)01330-1Data were taken from 1201 studies with 104 million participants in 184 countries, aged 30-79 years, with measurement of blood pressure and data on blood pressure treatment.Hypertension was defined as having systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, and/or taking medication for hypertension.The Republic of Korea in this press release is indicated as South Korea in the associated paper.Imperial College LondonImperial College London is one of the world's leading universities. The College's 20 000 students and 8000 staff are working to solve the biggest challenges in science, medicine, engineering and business.Imperial is the world’s fifth most international university, according to Times Higher Education, with academic ties to more than 150 countries. Reuters named the College as the UK's most innovative university because of its exceptional entrepreneurial culture and ties to industry.Imperial staff, students and alumni are working round-the-clock to combat buy antibiotics.

Imperial has nearly two thousand key workers, and is at the forefront of antibiotics epidemiology, virology, treatment development and diagnostics. More than one thousand Imperial staff and students are volunteering to support the NHS. Http://www.imperial.ac.uk/The World Health OrganizationDedicated to the well-being of all people and guided by science, the World Health Organization (WHO) leads and champions global efforts to give everyone, everywhere an equal chance at a safe and healthy life.

WHO is the UN agency for heath that connects nations, partners and people on the front lines in 150+ locations – leading the world’s response to health emergencies, preventing disease, addressing the root causes of health issues and expanding access to medicines and health care. Our mission is to promote health, keep the world safe and serve the vulnerable. Www.who.intTop 10 countries with the lowest hypertension prevalence in 2019WOMEN Ranking Country Prevalence as % of population 1.

Switzerland 17% 2. Peru 18% 3. Canada 20% 4.

Taiwan (Province of China) 21% 5. Spain 21% 6. Republic of Korea 21% 7.

Japan 22% 8. United Kingdom 23% 9. China 24% 10.

Iceland 24% MEN Ranking Country Prevalence as % of population 1. Eritrea 22% 2. Peru 23% 3.

Bangladesh 24% 4. Canada 24% 5. Ethiopia 25% 6.

Solomon Islands 25% 7. Papua New Guinea 25% 8. Lao PDR 26% 9.

Cambodia 26% 10. Switzerland 26% Top 10 countries with the highest hypertension prevalence in 2019WOMEN Ranking Country Prevalence as % of population 1. Paraguay 51% 2.

Tuvalu 51% 3. Dominica 50% 4. Dominican Republic 49% 5.

Sao Tome and Principe 48% 6. Jamaica 48% 7. Haiti 48% 8.

Iraq 48% 9. Eswatini 47% 10. Botswana 47% MEN Ranking Country Prevalence as % of population 1.

Paraguay 62% 2. Hungary 56% 3. Poland 55% 4.

Argentina 54% 5. Lithuania 54% 6. Romania 53% 7.

Belarus 52% 8. Croatia 51% 9. Tajikistan 51% 10.

Serbia 50% Top 10 countries with the highest hypertension treatment rate in 2019WOMEN Ranking Country Rate as % of all women with hypertension 1. Republic of Korea 77% 2. Costa Rica 76% 3.

Kazakhstan 74% 4. United States of America 73% 5. Iceland 72% 6.

Venezuela 71% 7. El Salvador 71% 8. Portugal 71% 9.

Canada 71% 10. Slovakia 70% MEN Ranking Country Rate as % of all men with hypertension 1. Canada 76% 2.

Iceland 71% 3. Republic of Korea 67% 4. United States of America 66% 5.

Kazakhstan 66% 6. Malta 65% 7. Costa Rica 63% 8.

Germany 61% 9. Czechia 59% 10. Singapore 59% Top 10 countries with the lowest hypertension treatment rate in 2019WOMEN Ranking Country Rate as % of all women with hypertension 1.

Ethiopia 16% 5. Vanuatu 16% 6. Tanzania 17% 7.

Solomon Islands 17% 8. Madagascar 19% 9. Mozambique 19% 10.

Kenya 21% MEN Ranking Country Rate as % of all men with hypertension 1. Rwanda 10% 2. Kenya 10% 3.

Mozambique 10% 4. Vanuatu 11% 5. Solomon Islands 11% 6.

Niger 12% 7. Madagascar 13% 8. Uganda 13% 9.

Togo 14% 10. Burkina Faso 14% Top 10 countries with the largest increase in hypertension prevalence between 1990 and 2019WOMEN Ranking Country Percentage point increase (1990 - 2019) 1. Kiribati 13 2.

Brunei Darussalam 10 6. Haiti 9 7. Jamaica 9 8.

Myanmar 9 9. Samoa 9 10. Uzbekistan 9 MEN Ranking Country Percentage point increase (1990 - 2019) 1.

Uzbekistan 15 2. Argentina 13 3. Paraguay 10 4.

South Africa 10 5. China 10 6. Brunei Darussalam 9 7.

Tajikistan 8 8. Jamaica 8 9. Dominican Republic 8 10.

Tuvalu 8 Top 10 countries with the largest decline in hypertension prevalence between 1990 and 2019WOMEN Ranking Country Percentage point decrease (1990 - 2019) 1. Germany 18 2. Spain 14 3.

Japan 13 4. Singapore 12 5. Russian Federation 12 6.

Italy 12 7. Austria 11 8. United Kingdom 11 9.

Israel 11 10. Sweden 10 MEN Ranking Country Percentage point decrease (1990 - 2019) 1. Germany 19 2.

Switzerland 14 3. United Kingdom 13 4. Finland 12 5.

Austria 9 9. Italy 8 10. Malawi 8 Top 10 countries with the largest increase in treatment rate between 1990 and 2019WOMEN Ranking Country Percentage point increase (1990 - 2019) 1.

Republic of Korea 46 2. Taiwan (Province of China) 38 3. South Africa 36 4.

Costa Rica 35 5. Poland 35 6. Venezuela 35 7.

Serbia 33 8. Brunei Darussalam 33 9. Singapore 33 10.

Colombia 33 MEN Ranking Country Percentage point increase (1990 - 2019) 1. Republic of Korea 50 2. Canada 46 3.

Costa Rica 40 4. Germany 39 5. Iceland 39 6.

Taiwan (Province of China) 37 7. Kazakhstan 37 8. Poland 36 9.

Can you buy amoxil over the counter usa

Who should can you buy amoxil over the counter usa review their eligibility for 2022 health insurance subsidies?. The uninsured, many of who will be eligible for free or very low-cost health coverage Consumers who purchased coverage that’s not ACA-compliant Consumers who bought ‘off-exchange’ health plans Consumers enrolled in on-exchange plans, but who haven’t provide income details to the exchange or haven’t reconsidered their options recently For millions of Americans, the open enrollment period (OEP) to shop for 2022 ACA-compliant coverage will be unlike any of the previous eight OEPs. The reason? can you buy amoxil over the counter usa. These consumers will – for the first time – be able to tap into the Affordable Care Act’s premium tax credits (more commonly referred to as health insurance subsidies). Thanks to the American Rescue Plan, consumers who in previous years might have found themselves outside the eligible level for subsidies – or who may have found that subsidy amounts were so low as to not be enticing – are now among those eligible for premium tax credits.

So if you haven’t shopped for health insurance lately, you might be surprised to can you buy amoxil over the counter usa see how affordable your health coverage options are this fall (starting November 1), and how many plan options are available in your area. Millions have already tapped into the subsidies Most people who currently have coverage through the health insurance exchanges have seen improved affordability this year thanks to the American Rescue Plan (ARP). That includes millions of people who were already enrolled in plans when the ARP was enacted last March, as well as millions of others who signed up during the special enrollment period that continued through mid-August in most states (and is still ongoing in some states). Use our updated subsidy calculator to estimate how much you can save on your 2021 health insurance premiums can you buy amoxil over the counter usa. But there are still millions of others who are either uninsured or have obtained coverage elsewhere.

And there are also people who already had coverage in the exchange in 2021 but didn’t take the option to switch to a more robust plan after the ARP was implemented. If you’re in either of these categories, you don’t want to miss the open enrollment period in can you buy amoxil over the counter usa the fall of 2021. The Build Back Better Act, which is still under consideration in Congress, would extend the ARP’s subsidies and ensure that health insurance stays affordable in 2023 and beyond. But even without any new legislative action, most of the ARP’s subsidy enhancements will remain in place for 2022. That means there will continue to be no can you buy amoxil over the counter usa upper income limit for premium tax credit (subsidy) eligibility, and the percentage of income that people have to pay for the benchmark plan will continue to be lower than it was in prior years.

The overall result is that subsidies are larger than they were in the past, and available to more people. Who should make a point to review their subsidy eligibility?. So who needs to pay close attention this fall, during can you buy amoxil over the counter usa open enrollment?. In reality, anyone who doesn’t have access to Medicare, Medicaid, or an employer-sponsored health plan – because even if you’re already enrolled and happy with the plan you have, auto-renewal is not in your best interest. But there are several groups of people who really need to shop for coverage this fall.

Let’s take a look at what each of these groups can expect, and why you shouldn’t can you buy amoxil over the counter usa let open enrollment pass you by if you’re in one of these categories. 1. The uninsured – eligible for low-cost or NO-cost coverage The majority of uninsured Americans cite the cost of coverage as the reason they don’t have health insurance. Yet millions of those individuals are eligible for free or very low-cost health coverage but haven’t yet can you buy amoxil over the counter usa enrolled. This has been the case in prior years as well, but premium-free or very low-cost health plans are even more widely available as a result of the ARP.

If you’re uninsured because you don’t think health insurance is affordable, know that more than a third of the people who enrolled via HealthCare.gov during the buy antibiotics/ARP special enrollment period this year purchased plans for less than $10/month. Even if you’ve can you buy amoxil over the counter usa checked in previous years and couldn’t afford the plans that were available, you’ll want to check again this fall, since the subsidy rules have changed since last year. 2. Consumers enrolled in non-ACA-compliant plans There are millions of Americans who have purchased health coverage that isn’t compliant with the ACA. Most of these can you buy amoxil over the counter usa plans are either less robust than ACA-compliant plans, or use medical underwriting, or both.

They include. Health care sharing ministry plans Farm Bureau non-insurance plans Short-term health insurance plans Fixed indemnity plans Grandmothered plans (no longer for sale, but some plans remain in effect) Grandfathered plans (no longer for sale, but some plans remain in effect) Direct primary care (DPC) memberships Discount plans People purchase or keep these plans for a variety of reasons. But chief among them has long been the fact that ACA-compliant coverage was can you buy amoxil over the counter usa unaffordable – or was assumed to be unaffordable. There are also people who prefer some of the benefits that some of these plans offer (the fellowship of being part of a health care sharing ministry, for instance, or the abundantly available primary care with a DPC membership). But by and large, the reason people choose coverage that isn’t ACA-compliant, or that isn’t even insurance at all, is because ACA-compliant coverage doesn’t fit in their budgets.

This has long included a few main can you buy amoxil over the counter usa groups of people. Those who earned too much to qualify for subsidies, those affected by the “family glitch,” and those who qualified for only minimal subsidy assistance and still felt that the coverage available in the exchange wasn’t affordable. (Another group of people unable to afford coverage are those who earn less than the poverty level in 11 states that have refused to expand Medicaid and thus have a coverage gap. Some people in the coverage gap purchase non-ACA-compliant coverage, but this population is also likely to can you buy amoxil over the counter usa not have any coverage at all. If you or a loved one are in the coverage gap, we encourage you to read this article.) The ARP has not fixed the family glitch or the coverage gap, although there are legislative and administrative solutions under consideration for each of these.

But the ARP has addressed the other two issues, and those provisions remain in place for 2022. The income cap for subsidy eligibility has been eliminated, which means that some applicants can qualify for subsidies with income can you buy amoxil over the counter usa far above 400% of the poverty level. And for those who were already eligible for subsidies, the subsidy amounts are larger than they used to be, making coverage more affordable. So if you are enrolled in any sort of self-purchased health plan that isn’t compliant with the ACA, you owe it to yourself to check your on-exchange options this fall, during the open enrollment period. Keep in mind that can you buy amoxil over the counter usa you can do that through the exchange, through an enhanced direct enrollment entity, or with the assistance of a health insurance broker.

3. Buyers enrolled in off-exchange health plans There are also people who have “off-exchange” ACA-compliant plans that they’ve purchased directly from an insurance company, without using the exchange. (Note that this is not the same can you buy amoxil over the counter usa thing as enrolling in an on-exchange plans through an enhanced direct enrollment entity, many of which are insurance companies). There are a variety of reasons people have chosen to enroll in off-exchange health plans over the last several years. And for can you buy amoxil over the counter usa some of those enrollees, 2022 might be the year to switch to an on-exchange plan.

Since 2018, some people have opted for off-exchange plans if they weren’t eligible for premium subsidies and wanted to enroll in a Silver-level plan. This was a very rational choice, encouraged by state insurance commissioners and marketplaces alike. But if you’ve been buying off-exchange coverage in order to get a Silver plan with a lower price tag, the primary point to keep in mind for 2022 can you buy amoxil over the counter usa is that you might find that you’re now eligible for premium subsidies. Just like the people described above, who have enrolled in various non-ACA-compliant plans in an effort to obtain affordable coverage, the elimination of the income limit for subsidy eligibility is a game changer for people who were buying off-exchange coverage to get a lower price on a Silver plan. Some people have opted for off-exchange coverage because their preferred health insurer wasn’t participating in the exchange in their area.

This might have been a deciding factor for an applicant who was only can you buy amoxil over the counter usa eligible for a very small subsidy — or no subsidy at all — and was willing to pay full price for an off-exchange plan from the insurer of their choice. But 2022 is the fourth year in a row with increasing insurer participation in the exchanges, and some big-name insurers are joining or rejoining the exchanges in quite a few states. So if you haven’t checked your on-exchange options in a while, this fall is definitely the time to do so. You might can you buy amoxil over the counter usa be surprised to see how many options you have, and again, how affordable they are. 4.

Consumers enrolled in on-exchange plans, but no income details on file and no recent coverage reconsiderations If you’re already enrolled in an on-exchange plan and you had given the exchange a projection of your income for 2021, you probably saw your subsidy amount increase at some point this year. But if the exchange didn’t have an income on file for you, they wouldn’t have been able to activate a subsidy on your behalf (on the HealthCare.gov platform, subsidy amounts were automatically updated in September for can you buy amoxil over the counter usa people who hadn’t updated their accounts by that point, but only if you had provided a projected income to the exchange when you enrolled in coverage for 2021). And even if your subsidy amount did get updated, you might have remained on the plan you had picked last fall, despite the option to pick a different one after the ARP was enacted. The good news is that you’ll be able to claim your full premium tax credit, for the entirety of 2021, when you file your 2021 tax return (assuming you had on-exchange health coverage throughout the year). And during the open enrollment period for 2022 coverage, you can provide income information to the can you buy amoxil over the counter usa exchange so that a subsidy is paid on your behalf each month next year.

Reconsidering your plan choice during open enrollment might end up being beneficial as well. If you didn’t qualify for a subsidy in the past, or if you only qualified for a modest subsidy, you might have picked a Bronze plan or even a catastrophic plan, in an effort to keep your monthly premiums affordable. But with the ARP in place, you might find that you can afford a more robust can you buy amoxil over the counter usa health plan. And if your income doesn’t exceed 250% of the poverty level (and especially if it doesn’t exceed 200% of the poverty level), pay close attention to the available Silver plans. The larger subsidies may make it possible for you to afford a Silver plan with built-in cost-sharing reductions that significantly reduce out-of-pocket costs.

One other point to keep in mind can you buy amoxil over the counter usa. If you are receiving a premium subsidy this year, be aware that it might change next year due to a new insurer entering the market in your area and offering lower-priced plans. Here’s more about how this works, and what to consider as you’re shopping for coverage this fall. The takeaway point here? can you buy amoxil over the counter usa. Even if you’ve been happy with your plan, you should check your options during open enrollment.

This is not the year to let your plan auto-renew. Be sure can you buy amoxil over the counter usa you’ve provided the exchange with an updated income projection for 2022, and actively compare the plans that are available to you. It’s possible that a plan with better coverage or a broader provider network might be affordable to you for 2022, even if it was financially out of reach when you checked last fall. Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care can you buy amoxil over the counter usa Act for healthinsurance.org.

Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.The American Rescue Plan, signed into law by President Biden on March 11 of this year, included major boosts to the affordability of health plans sold in the ACA marketplace for people of all incomes. Effective through 2022 and likely to be made permanent by pending legislation, the ARP improvements to affordability were as follows. A benchmark Silver plan (the second least expensive Silver plan) with strong cost sharing reduction (CSR) subsidies became free to enrollees with household income up can you buy amoxil over the counter usa to 150% of the Federal Poverty Level (FPL) and costs no more than 2% of income for enrollees with income up to 200% FPL. That’s a maximum of $43 per month for a single person with an income of $25,520. The previous income cap on subsidy eligibility was removed, so that no one who lacks access to affordable coverage elsewhere (i.e., from an employer) has to pay more than 8.5% of income for a benchmark Silver plan (less at lower incomes).

The eliminated cap was 400% FPL ($51,040 for an individual, $104,880 for a family of four), and some households with income can you buy amoxil over the counter usa well above that level now qualify for subsidies. The percentage of income required to buy a benchmark Silver plan was reduced at all income levels. Anyone who received any unemployment insurance income during 2021 was eligible for free high-CSR Silver coverage. (Note that the pending legislation calls for this can you buy amoxil over the counter usa subsidy enhancement to be extended by several years, but not necessarily made permanent.) Our 2022 Open Enrollment Guide. Everything you need to know to enroll in an affordable individual-market health plan.

Preceding and then coinciding with these major subsidy boosts, the Biden administration had opened an emergency Special Enrollment Period (SEP) running from February 15 through August 15 in the 36 states that use the federal ACA exchange, HealthCare.gov. The SEP, implemented to help Americans get covered during the amoxil, functioned like a second open can you buy amoxil over the counter usa enrollment period. Anyone who lacked access to affordable coverage from other sources (e.g., employers) could enroll in a marketplace plan. The 15 state-based exchanges also opened emergency SEPs, with somewhat different durations and conditions, summarized here. ARP prompted an enrollment surge during the 2021 SEP The enhanced can you buy amoxil over the counter usa subsidies were posted on HealthCare.gov on April 1, and in the state-run exchanges within a few weeks of that date.

Existing enrollees were encouraged to update their information and get the new subsidies credited, and were allowed to switch plans if they chose. Americans responded with a major surge in new enrollment and enrollment upgrades. From February can you buy amoxil over the counter usa 15 through August 15. More than 2.8 million people enrolled in new health coverage. Of new enrollees, 91% qualified for premium subsidies can you buy amoxil over the counter usa.

Of new enrollees, 44% obtained coverage for less than $10 per month. Most of these enrollees (41% in HealthCare.gov states) received free coverage with the highest level of CSR. As a result, the median deductible fell from $750 in 2020 to $50 this year – meaning that half of enrollees obtained a plan with a deductible at or below can you buy amoxil over the counter usa that level (most of them in high-CSR Silver plans). The average premium paid by new consumers during the SEP (Feb. 15 – Aug.

15) fell 30%, from can you buy amoxil over the counter usa $117 in 2020 to $81 in 2021. Marketplace enrollment in August 2021, at 12.2 million, was 15% higher than in August 2020, the previous August high, and 22% above the pre-amoxil August high (see p. 14 here) recorded in 2016. More than can you buy amoxil over the counter usa 200,000 new and existing enrollees qualified for free high-CSR Silver plans because they had received unemployment insurance income in 2021. Savings were also dramatic for existing marketplace enrollees.

8 million existing enrollees reduced the premiums on their existing plans or obtained new plans after ARP implementation. Existing enrollees reduced their premiums by can you buy amoxil over the counter usa 50%, or by $67 per month, on average. My premium went down how much?. To get a sense of the extent to which the ARP reduced enrollee costs (or encouraged people who might previously have considered coverage too expensive to enroll), consider these examples. In November 2020, a 40-year-old in Miami with an income of $24,000 per year would have paid $115 per month for the least expensive available Silver plan, with a $1,500 deductible, and $119 per month for the second-cheapest Silver plan, can you buy amoxil over the counter usa with a $0 deductible.

Thanks to the ARP, those plans would now cost this person $26 and $30 per month, respectively. In November 2020, a pair of 60-year-olds in Dallas, Texas with an income of $70,000 – slightly over the income cap for premium subsidies, which the ARP eliminated – would have had to pay $1,669 per month for the lowest cost Gold plan, with a $2,300 deductible (Gold plans are cheaper than Silver Plans in Dallas), or $1,228 for the lowest cost Bronze plan, with an $8,550 deductible. Now, this couple can choose to pay $393 per month for the Gold plan (which includes free doctor visits and generic can you buy amoxil over the counter usa drug prescriptions, neither subject to the deductible), or consider two free Bronze plans with deductibles over $8,000, a $2/month Bronze plan with a $6,100 deductible, and other options. A BlueCross Silver plan available for $420 per month might also be in the mix, if, say, the provider network is preferable. Which states saw the biggest gains in new enrollees?.

The can you buy amoxil over the counter usa new enrollment surge – and the savings – was particularly strong in twelve states that had not enacted the ACA Medicaid expansion as of June 2021. Due to their failure to expand Medicaid, these states have a “coverage gap” for people who earn too little to qualify for marketplace coverage (less than 100% FPL, or $12,760 for an individual in 2021) but mostly also don’t qualify for Medicaid because of their states’ restrictive Medicaid eligibility. (That excludes Wisconsin, which has not enacted the ACA expansion but grants Medicaid eligibility to adults with income up to 100% FPL. Oklahoma, which expanded Medicaid beginning in July 2021, and Missouri, which will begin covering new Medicaid expansion can you buy amoxil over the counter usa enrollees in October, are included.) These twelve states – Alabama, Florida, Georgia, Kansas, Missouri, Mississippi, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas and Wyoming – accounted for 1.55 million new enrollees during the SEP, or 55% of all new enrollees nationally. In the non-expansion states, eligibility for marketplace subsidies begins at 100% FPL, as opposed to 138% FPL in Medicaid expansion states, where adults below that threshold qualify for Medicaid.

Accordingly, in these states, about half of enrollees qualified for free high-CSR coverage, reporting incomes between 100% and 150% FPL. In these states, enrollment as of August 2021 (6.0 million) was 44% above enrollment in August 2019, the last pre-amoxil year (4.2 million) can you buy amoxil over the counter usa. More than 2 million people in non-expansion states are estimated to be stuck in the coverage gap – ineligible both for Medicaid and for ACA premium subsidies. For people in these states, reporting an income just below or just above 100% FPL ($12,760 for an individual, $26,200 for a family of four) is the difference between receiving no help at all and having access to free Silver coverage with high CSR and low out-of-pocket costs. It’s important to keep in mind that the application for marketplace coverage requires an income estimate – and many people, unaware of the can you buy amoxil over the counter usa minimum income requirement, underestimate their potential income.

For tips on how to make sure you leave no stone unturned in seeking help paying for coverage, see this post. What do these numbers mean for 2022 open enrollment?. As open can you buy amoxil over the counter usa enrollment for 2022 approaches (it begins on November 1), the subsidies enhanced by the ARP remain in place for 2022. As Congress hashes out new investments for coming years in a pending budget bill, the pressure is intense to keep this good thing going in future years. As of now, with the sad exception of those stuck in the coverage gap in states that still refuse to enact the ACA Medicaid expansion, any citizen or legally present noncitizen who lacks access to other forms of affordable coverage should be able to find it in the marketplace.

If you can you buy amoxil over the counter usa need coverage, make sure to check out your options on HealthCare.gov or your state exchange. The word that ACA marketplace plans are more affordable than ever has not yet reached many of the people who need coverage and qualify for premium subsidies. The Kaiser Family Foundation estimated in May that nearly 11 million uninsured people were subsidy-eligible. ACA enrollment assisters can you buy amoxil over the counter usa consistently report that many people who are eligible for coverage have no idea what’s on offer. The Biden administration is trying to change that.

After years of radical cuts in federal funds for enrollment assistance, the administration this year has allocated a record $80 million to fund nonprofit enrollment “navigator” groups charged with outreach as well as enrollment assistance. The Urban Institute forecast that if the ARP subsidies are made permanent – solidifying the perception that truly affordable coverage is here to stay — enrollment would increase can you buy amoxil over the counter usa by more than 5 million in 2022. The emergency SEP provided a jump start, boosting coverage as of August more than 1.5 million above the August 2020 level. In a fraught and complex legislative session, Congress will most likely – though not certainly – do its part and extend the subsidies beyond 2022. There is certainly room for enrollment can you buy amoxil over the counter usa to run higher in the open enrollment season that begins on November 1.

Andrew Sprung is a freelance writer who blogs about politics and healthcare policy at xpostfactoid. His articles about the Affordable Care Act have appeared in publications including The American Prospect, Health Affairs, The Atlantic, and The New Republic. He is the winner of the National Institute of Health Care Management’s 2016 Digital Media Award. He holds a Ph.D. In English literature from the University of Rochester..

Who should review their eligibility for buy 250mg amoxil online 2022 health my link insurance subsidies?. The uninsured, many of who will be eligible for free or very low-cost health coverage Consumers who purchased coverage that’s not ACA-compliant Consumers who bought ‘off-exchange’ health plans Consumers enrolled in on-exchange plans, but who haven’t provide income details to the exchange or haven’t reconsidered their options recently For millions of Americans, the open enrollment period (OEP) to shop for 2022 ACA-compliant coverage will be unlike any of the previous eight OEPs. The reason? buy 250mg amoxil online.

These consumers will – for the first time – be able to tap into the Affordable Care Act’s premium tax credits (more commonly referred to as health insurance subsidies). Thanks to the American Rescue Plan, consumers who in previous years might have found themselves outside the eligible level for subsidies – or who may have found that subsidy amounts were so low as to not be enticing – are now among those eligible for premium tax credits. So if you buy 250mg amoxil online haven’t shopped for health insurance lately, you might be surprised to see how affordable your health coverage options are this fall (starting November 1), and how many plan options are available in your area.

Millions have already tapped into the subsidies Most people who currently have coverage through the health insurance exchanges have seen improved affordability this year thanks to the American Rescue Plan (ARP). That includes millions of people who were already enrolled in plans when the ARP was enacted last March, as well as millions of others who signed up during the special enrollment period that continued through mid-August in most states (and is still ongoing in some states). Use our updated subsidy calculator to estimate how much you can save buy 250mg amoxil online on your 2021 health insurance premiums.

But there are still millions of others who are either uninsured or have obtained coverage elsewhere. And there are also people who already had coverage in the exchange in 2021 but didn’t take the option to switch to a more robust plan after the ARP was implemented. If you’re in either buy 250mg amoxil online of these categories, you don’t want to miss the open enrollment period in the fall of 2021.

The Build Back Better Act, which is still under consideration in Congress, would extend the ARP’s subsidies and ensure that health insurance stays affordable in 2023 and beyond. But even without any new legislative action, most of the ARP’s subsidy enhancements will remain in place for 2022. That means there will continue to be no upper income limit for premium tax credit (subsidy) buy 250mg amoxil online eligibility, and the percentage of income that people have to pay for the benchmark plan will continue to be lower than it was in prior years.

The overall result is that subsidies are larger than they were in the past, and available to more people. Who should make a point to review their subsidy eligibility?. So who needs to pay close attention this buy 250mg amoxil online fall, during open enrollment?.

In reality, anyone who doesn’t have access to Medicare, Medicaid, or an employer-sponsored health plan – because even if you’re already enrolled and happy with the plan you have, auto-renewal is not in your best interest. But there are several groups of people who really need to shop for coverage this fall. Let’s take a look at what buy 250mg amoxil online each of these groups can expect, and why you shouldn’t let open enrollment pass you by if you’re in one of these categories.

1. The uninsured – eligible for low-cost or NO-cost coverage The majority of uninsured Americans cite the cost of coverage as the reason they don’t have health insurance. Yet millions of those individuals are eligible for free or very low-cost health buy 250mg amoxil online coverage but haven’t yet enrolled.

This has been the case in prior years as well, but premium-free or very low-cost health plans are even more widely available as a result of the ARP. If you’re uninsured because you don’t think health insurance is affordable, know that more than a third of the people who enrolled via HealthCare.gov during the buy antibiotics/ARP special enrollment period this year purchased plans for less than $10/month. Even if you’ve checked in buy 250mg amoxil online previous years and couldn’t afford the plans that were available, you’ll want to check again this fall, since the subsidy rules have changed since last year.

2. Consumers enrolled in non-ACA-compliant plans There are millions of Americans who have purchased health coverage that isn’t compliant with the ACA. Most of these plans are either less robust than ACA-compliant plans, or use medical underwriting, buy 250mg amoxil online or both.

They include. Health care sharing ministry plans Farm Bureau non-insurance plans Short-term health insurance plans Fixed indemnity plans Grandmothered plans (no longer for sale, but some plans remain in effect) Grandfathered plans (no longer for sale, but some plans remain in effect) Direct primary care (DPC) memberships Discount plans People purchase or keep these plans for a variety of reasons. But chief among them has long been the fact that buy 250mg amoxil online ACA-compliant coverage was unaffordable – or was assumed to be unaffordable.

There are also people who prefer some of the benefits that some of these plans offer (the fellowship of being part of a health care sharing ministry, for instance, or the abundantly available primary care with a DPC membership). But by and large, the reason people choose coverage that isn’t ACA-compliant, or that isn’t even insurance at all, is because ACA-compliant coverage doesn’t fit in their budgets. This has long included a few main groups buy 250mg amoxil online of people.

Those who earned too much to qualify for subsidies, those affected by the “family glitch,” and those who qualified for only minimal subsidy assistance and still felt that the coverage available in the exchange wasn’t affordable. (Another group of people unable to afford coverage are those who earn less than the poverty level in 11 states that have refused to expand Medicaid and thus have a coverage gap. Some people in the coverage gap purchase non-ACA-compliant coverage, but this population is also likely to not have any buy 250mg amoxil online coverage at all.

If you or a loved one are in the coverage gap, we encourage you to read this article.) The ARP has not fixed the family glitch or the coverage gap, although there are legislative and administrative solutions under consideration for each of these. But the ARP has addressed the other two issues, and those provisions remain in place for 2022. The income cap for subsidy eligibility has been eliminated, which means that some applicants can qualify for subsidies with income far above 400% buy 250mg amoxil online of the poverty level.

And for those who were already eligible for subsidies, the subsidy amounts are larger than they used to be, making coverage more affordable. So if you are enrolled in any sort of self-purchased health plan that isn’t compliant with the ACA, you owe it to yourself to check your on-exchange options this fall, during the open enrollment period. Keep in mind that you can do that through the exchange, through an enhanced direct buy 250mg amoxil online enrollment entity, or with the assistance of a health insurance broker.

3. Buyers enrolled in off-exchange health plans There are also people who have “off-exchange” ACA-compliant plans that they’ve purchased directly from an insurance company, without using the exchange. (Note that this is not the same thing as enrolling in an on-exchange plans through an enhanced direct enrollment entity, many buy 250mg amoxil online of which are insurance companies).

There are a variety of reasons people have chosen to enroll in off-exchange health plans over the last several years. And for some of those enrollees, 2022 might be buy 250mg amoxil online the year to switch to an on-exchange plan. Since 2018, some people have opted for off-exchange plans if they weren’t eligible for premium subsidies and wanted to enroll in a Silver-level plan.

This was a very rational choice, encouraged by state insurance commissioners and marketplaces alike. But if you’ve been buying off-exchange coverage in order to get a Silver plan with a lower price tag, the primary point to keep buy 250mg amoxil online in mind for 2022 is that you might find that you’re now eligible for premium subsidies. Just like the people described above, who have enrolled in various non-ACA-compliant plans in an effort to obtain affordable coverage, the elimination of the income limit for subsidy eligibility is a game changer for people who were buying off-exchange coverage to get a lower price on a Silver plan.

Some people have opted for off-exchange coverage because their preferred health insurer wasn’t participating in the exchange in their area. This might have been a buy 250mg amoxil online deciding factor for an applicant who was only eligible for a very small subsidy — or no subsidy at all — and was willing to pay full price for an off-exchange plan from the insurer of their choice. But 2022 is the fourth year in a row with increasing insurer participation in the exchanges, and some big-name insurers are joining or rejoining the exchanges in quite a few states.

So if you haven’t checked your on-exchange options in a while, this fall is definitely the time to do so. You might be surprised to buy 250mg amoxil online see how many options you have, and again, how affordable they are. 4.

Consumers enrolled in on-exchange plans, but no income details on file and no recent coverage reconsiderations If you’re already enrolled in an on-exchange plan and you had given the exchange a projection of your income for 2021, you probably saw your subsidy amount increase at some point this year. But if the exchange didn’t have an income on file for you, they wouldn’t have been able to activate buy 250mg amoxil online a subsidy on your behalf (on the HealthCare.gov platform, subsidy amounts were automatically updated in September for people who hadn’t updated their accounts by that point, but only if you had provided a projected income to the exchange when you enrolled in coverage for 2021). And even if your subsidy amount did get updated, you might have remained on the plan you had picked last fall, despite the option to pick a different one after the ARP was enacted.

The good news is that you’ll be able to claim your full premium tax credit, for the entirety of 2021, when you file your 2021 tax return (assuming you had on-exchange health coverage throughout the year). And during the open enrollment period for buy 250mg amoxil online 2022 coverage, you can provide income information to the exchange so that a subsidy is paid on your behalf each month next year. Reconsidering your plan choice during open enrollment might end up being beneficial as well.

If you didn’t qualify for a subsidy in the past, or if you only qualified for a modest subsidy, you might have picked a Bronze plan or even a catastrophic plan, in an effort to keep your monthly premiums affordable. But with the ARP in place, you might find that you can afford a more robust health plan buy 250mg amoxil online. And if your income doesn’t exceed 250% of the poverty level (and especially if it doesn’t exceed 200% of the poverty level), pay close attention to the available Silver plans.

The larger subsidies may make it possible for you to afford a Silver plan with built-in cost-sharing reductions that significantly reduce out-of-pocket costs. One other point to keep in mind buy 250mg amoxil online. If you are receiving a premium subsidy this year, be aware that it might change next year due to a new insurer entering the market in your area and offering lower-priced plans.

Here’s more about how this works, and what to consider as you’re shopping for coverage this fall. The takeaway point here? buy 250mg amoxil online. Even if you’ve been happy with your plan, you should check your options during open enrollment.

This is not the year to let your plan auto-renew. Be sure you’ve buy 250mg amoxil online provided the exchange with an updated income projection for 2022, and actively compare the plans that are available to you. It’s possible that a plan with better coverage or a broader provider network might be affordable to you for 2022, even if it was financially out of reach when you checked last fall.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces buy 250mg amoxil online about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.The American Rescue Plan, signed into law by President Biden on March 11 of this year, included major boosts to the affordability of health plans sold in the ACA marketplace for people of all incomes.

Effective through 2022 and likely to be made permanent by pending legislation, the ARP improvements to affordability were as follows. A benchmark Silver plan (the second least expensive Silver plan) with strong cost sharing reduction (CSR) subsidies became free to buy 250mg amoxil online enrollees with household income up to 150% of the Federal Poverty Level (FPL) and costs no more than 2% of income for enrollees with income up to 200% FPL. That’s a maximum of $43 per month for a single person with an income of $25,520.

The previous income cap on subsidy eligibility was removed, so that no one who lacks access to affordable coverage elsewhere (i.e., from an employer) has to pay more than 8.5% of income for a benchmark Silver plan (less at lower incomes). The eliminated cap was 400% FPL ($51,040 for an individual, $104,880 for a family of four), and some households with income well above that level now qualify for subsidies buy 250mg amoxil online. The percentage of income required to buy a benchmark Silver plan was reduced at all income levels.

Anyone who received any unemployment insurance income during 2021 was eligible for free high-CSR Silver coverage. (Note that the pending legislation calls for this subsidy enhancement to be extended by several years, but not buy 250mg amoxil online necessarily made permanent.) Our 2022 Open Enrollment Guide. Everything you need to know to enroll in an affordable individual-market health plan.

Preceding and then coinciding with these major subsidy boosts, the Biden administration had opened an emergency Special Enrollment Period (SEP) running from February 15 through August 15 in the 36 states that use the federal ACA exchange, HealthCare.gov. The SEP, implemented to help Americans get covered during the amoxil, functioned like a second open buy 250mg amoxil online enrollment period. Anyone who lacked access to affordable coverage from other sources (e.g., employers) could enroll in a marketplace plan.

The 15 state-based exchanges also opened emergency SEPs, with somewhat different durations and conditions, summarized here. ARP prompted an enrollment surge during the 2021 SEP The enhanced subsidies were posted buy 250mg amoxil online on HealthCare.gov on April 1, and in the state-run exchanges within a few weeks of that date. Existing enrollees were encouraged to update their information and get the new subsidies credited, and were allowed to switch plans if they chose.

Americans responded with a major surge in new enrollment and enrollment upgrades. From February 15 buy 250mg amoxil online through August 15. More than 2.8 million people enrolled in new health coverage.

Of new enrollees, 91% qualified for buy 250mg amoxil online premium subsidies. Of new enrollees, 44% obtained coverage for less than $10 per month. Most of these enrollees (41% in HealthCare.gov states) received free coverage with the highest level of CSR.

As a result, buy 250mg amoxil online the median deductible fell from $750 in 2020 to $50 this year – meaning that half of enrollees obtained a plan with a deductible at or below that level (most of them in high-CSR Silver plans). The average premium paid by new consumers during the SEP (Feb. 15 – Aug.

15) fell buy 250mg amoxil online 30%, from $117 in 2020 to $81 in 2021. Marketplace enrollment in August 2021, at 12.2 million, was 15% higher than in August 2020, the previous August high, and 22% above the pre-amoxil August high (see p. 14 here) recorded in 2016.

More than buy 250mg amoxil online 200,000 new and existing enrollees qualified for free high-CSR Silver plans because they had received unemployment insurance income in 2021. Savings were also dramatic for existing marketplace enrollees. 8 million existing enrollees reduced the premiums on their existing plans or obtained new plans after ARP implementation.

Existing enrollees reduced their premiums by 50%, or by $67 per buy 250mg amoxil online month, on average. My premium went down how much?. To get a sense of the extent to which the ARP reduced enrollee costs (or encouraged people who might previously have considered coverage too expensive to enroll), consider these examples.

In November 2020, a 40-year-old in Miami with an income of $24,000 per year would have paid $115 per month for the least expensive available Silver plan, with a $1,500 deductible, and $119 per month for the second-cheapest Silver plan, with a $0 deductible buy 250mg amoxil online. Thanks to the ARP, those plans would now cost this person $26 and $30 per month, respectively. In November 2020, a pair of 60-year-olds in Dallas, Texas with an income of $70,000 – slightly over the income cap for premium subsidies, which the ARP eliminated – would have had to pay $1,669 per month for the lowest cost Gold plan, with a $2,300 deductible (Gold plans are cheaper than Silver Plans in Dallas), or $1,228 for the lowest cost Bronze plan, with an $8,550 deductible.

Now, this couple can choose to pay $393 per month for the Gold plan (which includes free doctor visits and generic drug prescriptions, neither subject to the deductible), or consider two free buy 250mg amoxil online Bronze plans with deductibles over $8,000, a $2/month Bronze plan with a $6,100 deductible, and other options. A BlueCross Silver plan available for $420 per month might also be in the mix, if, say, the provider network is preferable. Which states saw the biggest gains in new enrollees?.

The new enrollment buy 250mg amoxil online surge – and the savings – was particularly strong in twelve states that had not enacted the ACA Medicaid expansion as of June 2021. Due to their failure to expand Medicaid, these states have a “coverage gap” for people who earn too little to qualify for marketplace coverage (less than 100% FPL, or $12,760 for an individual in 2021) but mostly also don’t qualify for Medicaid because of their states’ restrictive Medicaid eligibility. (That excludes Wisconsin, which has not enacted the ACA expansion but grants Medicaid eligibility to adults with income up to 100% FPL.

Oklahoma, which expanded Medicaid beginning buy 250mg amoxil online in July 2021, and Missouri, which will begin covering new Medicaid expansion enrollees in October, are included.) These twelve states – Alabama, Florida, Georgia, Kansas, Missouri, Mississippi, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas and Wyoming – accounted for 1.55 million new enrollees during the SEP, or 55% of all new enrollees nationally. In the non-expansion states, eligibility for marketplace subsidies begins at 100% FPL, as opposed to 138% FPL in Medicaid expansion states, where adults below that threshold qualify for Medicaid. Accordingly, in these states, about half of enrollees qualified for free high-CSR coverage, reporting incomes between 100% and 150% FPL.

In these states, enrollment as of August 2021 (6.0 million) buy 250mg amoxil online was 44% above enrollment in August 2019, the last pre-amoxil year (4.2 million). More than 2 million people in non-expansion states are estimated to be stuck in the coverage gap – ineligible both for Medicaid and for ACA premium subsidies. For people in these states, reporting an income just below or just above 100% FPL ($12,760 for an individual, $26,200 for a family of four) is the difference between receiving no help at all and having access to free Silver coverage with high CSR and low out-of-pocket costs.

It’s important to keep in mind that the application for marketplace coverage requires an income estimate – and many buy 250mg amoxil online people, unaware of the minimum income requirement, underestimate their potential income. For tips on how to make sure you leave no stone unturned in seeking help paying for coverage, see this post. What do these numbers mean for 2022 open enrollment?.

As open enrollment for 2022 approaches (it begins on November 1), the buy 250mg amoxil online subsidies enhanced by the ARP remain in place for 2022. As Congress hashes out new investments for coming years in a pending budget bill, the pressure is intense to keep this good thing going in future years. As of now, with the sad exception of those stuck in the coverage gap in states that still refuse to enact the ACA Medicaid expansion, any citizen or legally present noncitizen who lacks access to other forms of affordable coverage should be able to find it in the marketplace.

If you buy 250mg amoxil online need coverage, make sure to check out your options on HealthCare.gov or your state exchange. The word that ACA marketplace plans are more affordable than ever has not yet reached many of the people who need coverage and qualify for premium subsidies. The Kaiser Family Foundation estimated in May that nearly 11 million uninsured people were subsidy-eligible.

ACA enrollment assisters consistently report buy 250mg amoxil online that many people who are eligible for coverage have no idea what’s on offer. The Biden administration is trying to change that. After years of radical cuts in federal funds for enrollment assistance, the administration this year has allocated a record $80 million to fund nonprofit enrollment “navigator” groups charged with outreach as well as enrollment assistance.

The Urban Institute forecast that if the ARP subsidies are made permanent – solidifying the perception that truly affordable coverage is here to buy 250mg amoxil online stay — enrollment would increase by more than 5 million in 2022. The emergency SEP provided a jump start, boosting coverage as of August more than 1.5 million above the August 2020 level. In a fraught and complex legislative session, Congress will most likely – though not certainly – do its part and extend the subsidies beyond 2022.

There is certainly room for enrollment to run higher in the buy 250mg amoxil online open enrollment season that begins on November 1. Andrew Sprung is a freelance writer who blogs about politics and healthcare policy at xpostfactoid. His articles about the Affordable Care Act have appeared in publications including The American Prospect, Health Affairs, The Atlantic, and The New Republic.

He is the winner of the National buy 250mg amoxil online Institute of Health Care Management’s 2016 Digital Media Award. He holds a Ph.D. In English literature from the University of Rochester..

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How to cite this where can i buy amoxil over the counter article:Singh OP. Psychiatry research in India. Closing the where can i buy amoxil over the counter research gap. Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science. Research in India in general and medical where can i buy amoxil over the counter research in particular is always being criticized for lack of innovation and originality required for the delivery of health services suitable to Indian conditions.

Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output where can i buy amoxil over the counter of ICMR is not up to the mark and is not commensurate with the magnitude of the disease burden in India. According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases. The research conducted elsewhere may not be generalized to the Indian population owing to differences in biology, where can i buy amoxil over the counter health-care systems, health practices, culture, and socioeconomic standards.

Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017–2018) of the Department of Health Research observed that “the biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.”[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research. While ICMR has a budget of 232 million dollars per where can i buy amoxil over the counter year on health research, it is zilch in comparison to the annual budget expenditure of the National Institute of Health, USA, on biomedical research which is 32 billion dollars.The lacuna of quality research is not merely due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and where can i buy amoxil over the counter established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical institutions.

The majority of these are done as thesis submission for fulfillment of the requirement of PG degree. From 2015 onward, publication of where can i buy amoxil over the counter papers had been made an obligatory requirement for promotion of faculty to higher posts. Although it offered a unique opportunity for training of residents and stimulus for research, it failed to translate into production of quality research work as thesis was limited by time and it had to be done with other clinical and academic duties.While the top four medical colleges, namely AIIMS, New Delhi. PGIMER, Chandigarh. CMC, Vellore where can i buy amoxil over the counter.

And SGIMS, Lucknow are among the top ten medical institutions in terms of publication in peer-reviewed journals, around 332 (57.3%) medical colleges have no research paper published in a decade between 2004 and 2014.[2]The research in psychiatry is realistically dominated by major research institutes which are doing commendable work, but there is a substantial lack of contemporary research originating from other centers. Dr. Chittaranjan Andrade (NIMHANS, Bengaluru) and Dr. K Jacob (CMC, Vellore) recently figured in the list of top 2% psychiatry researchers in the world from India in psychiatry.[3] Most of the research conducted in the field of psychiatry are limited to caregivers' burden, pathways of care, and other topics which can be done in limited resources available to psychiatry departments. While all these areas of work are important in providing proper care and treatment, there is overabundance of research in these areas.The Government of India is aggressively looking forward to enhancing the quality of research and is embarking on an ambitious project of purchasing all major journals and providing free access to universities across the country.

The India Genome Project started in January, 2020, is a good example of collaboration. While all these actions are laudable, a lot more needs to be done. Following are some measures which will reduce the gap:Research proposals at the level of protocol can be guided and mentored by institutes. Academic committees of different zones and journals can help in this endeavorBreaking the cubicles by establishing a collaboration between medical colleges and various institutes. While there is a lack of resources available in individual departments, there are universities and institutes with excellent infrastructure.

They are not aware of the requirements of the field of psychiatry and research questions. Creation of an alliance will enhance the quality of research work. Some of such institutes include Centre for Neuroscience, Indian Institute of Science, Bengaluru. CSIR-Institute of Genomics and Integrative Biology, New Delhi. And National Institute of Biomedical Genomics, KalyaniInitiation and establishment of interactive and stable relationships between basic scientists and clinical and technological experts will enhance the quality of research work and will lead to translation of basic biomedical research into real-time applications.

For example, work on artificial intelligence for mental health. Development of Apps by IITs. Genome India Project by the Government of India, genomic institutes, and social science and economic institutes working in the field of various aspects of mental healthUtilization of underutilized, well-equipped biotechnological labs of nonmedical colleges for furthering biomedical researchMedical colleges should collaborate with various universities which have labs providing testing facilities such as spectroscopy, fluoroscopy, gamma camera, scintigraphy, positron emission tomography, single photon emission computed tomography, and photoacoustic imagingCreating an interactive, interdepartmental, intradepartmental, and interinstitutional partnershipBy developing a healthy and ethical partnership with industries for research and development of new drugs and interventions.Walking the talk – the psychiatric fraternity needs to be proactive and rather than lamenting about the lack of resource, we should rise to the occasion and come out with innovative and original research proposals. With the implementation of collaborative approach, we can not only enhance and improve the quality of our research but to an extent also mitigate the effects of resource crunch and come up as a leader in the field of biomedical research. References 1.2.Nagoba B, Davane M.

Current status of medical research in India. Where are we?. Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J. Updated science-wide author databases of standardized citation indicators.

PLoS Biol 2020;18:e3000918. Correspondence Address:Dr. Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/indianjpsychiatry.indianjpsychiatry_1362_2Abstract Background. The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly.Aim. The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research.Materials and Methods. Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis. PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies.

Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme. Studies were summarized and reported descriptively.Results. Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas. Alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services.

Sociocultural factors play a major role in understanding and determining mental disorders.Conclusion. This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality. Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.Keywords. India, mental health, scheduled tribesHow to cite this article:Devarapalli S V, Kallakuri S, Salam A, Maulik PK.

Mental health research on scheduled tribes in India. Indian J Psychiatry 2020;62:617-30 Introduction Mental health is a highly neglected area particularly in low and middle-income countries (LMIC). Data from community-based studies showed that about 10% of people suffer from common mental disorders (CMDs) such as depression, anxiety, and somatic complaints.[1] A systematic review of epidemiological studies between 1960 and 2009 in India reported that about 20% of the adult population in the community are affected by psychiatric disorders in the community, ranging from 9.5 to 103/1000 population, with differences in case definitions, and methods of data collection, accounting for most of the variation in estimates.[2]The scheduled tribes (ST) population is a marginalized community and live in relative social isolation with poorer health indices compared to similar nontribal populations.[3] There are an estimated 90 million STs or Adivasis in India.[4] They constitute 8.6% of the total Indian population. The distribution varies across the states and union territories of India, with the highest percentage in Lakshadweep (94.8%) followed by Mizoram (94.4%). In northeastern states, they constitute 65% or more of the total population.[5] The ST communities are identified as culturally or ethnographically unique by the Indian Constitution.

They are populations with poorer health indicators and fewer health-care facilities compared to non-ST rural populations, even when within the same state, and often live in demarcated geographical areas known as ST areas.[4]As per the National Family Health Survey, 2015–2016, the health indicators such as infant mortality rate (IMR) is 44.4, under five mortality rate (U5MR) is 57.2, and anemia in women is 59.8 for STs – one of the most disadvantaged socioeconomic groups in India, which are worse compared to other populations where IMR is 40.7, U5MR is 49.7, and anemia in women among others is 53.0 in the same areas.[6] Little research is available on the health of ST population. Tribal mental health is an ignored and neglected area in the field of health-care services. Further, little data are available about the burden of mental disorders among the tribal communities. Health research on tribal populations is poor, globally.[7] Irrespective of the data available, it is clear that they have worse health indicators and less access to health facilities.[8] Even less is known about the burden of mental disorders in ST population. It is also found that the traditional livelihood system of the STs came into conflict with the forces of modernization, resulting not only in the loss of customary rights over the livelihood resources but also in subordination and further, developing low self-esteem, causing great psychological stress.[4] This community has poor health infrastructure and even less mental health resources, and the situation is worse when compared to other communities living in similar areas.[9],[10]Only 15%–25% of those affected with mental disorders in LMICs receive any treatment for their mental illness,[11] resulting in a large “treatment gap.”[12] Treatment gaps are more in rural populations,[13] especially in ST communities in India, which have particularly poor infrastructure and resources for health-care delivery in general, and almost no capacity for providing mental health care.[14]The aim of this systematic review was to explore the extent and nature of mental health research on ST population in India and to identify gaps and inform future research.

Materials and Methods Search strategyWe searched major databases (PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar) and made hand searches from January 1980 to December 2018 to identify relevant literature. Hand search refers to searching through medical journals which are not indexed in the major electronic databases such as Embase, for instance, searching for Indian journals in IndMed database as most of these journals are not available in major databases. Physical search refers to searching the journals that were not available online or were not available online during the study years. We used relevant Medical Subject Heading and key terms in our search strategy, as follows. €œMental health,” “Mental disorders,” “Mental illness,” “Psychiatry,” “Scheduled Tribe” OR “Tribe” OR “Tribal Population” OR “Indigenous population,” “India,” “Psych*” (Psychiatric, psychological, psychosis).Inclusion criteriaStudies published between January 1980 and December 2018 were included.

Studies on mental disorders were included only when they focused on ST population. Both qualitative and quantitative studies on mental disorders of ST population only were included in the analysis.Exclusion criteriaStudies without any primary data and which are merely overviews and commentaries and those not focused on ST population were excluded from the analysis.Data management and analysisTwo researchers (SD and SK) initially screened the title and abstract of each record to identify relevant papers and subsequently screened full text of those relevant papers. Any disagreements between the researchers were resolved by discussion or by consulting with an adjudicator (PKM). From each study, data were extracted on objectives, study design, study population, study duration, interventions (if applicable), outcomes, and results. Quality of the included studies was assessed, independently by three researchers (SD, SK, and AS), using Critical Appraisal Checklist developed by Critical Appraisal Skills Programme (CASP).[15] After a thorough qualitative assessment, all quantitative data were generated and tabulated.

A narrative description of the studies is provided in [Table 1] using some broad categories. Results Search resultsOur search retrieved 2306 records (which included hand-searched articles), of which after removing duplicates, title and abstracts of 2278 records were screened. Of these, 178 studies were deemed as potentially relevant and were reviewed in detail. Finally, we excluded 146 irrelevant studies and 32 studies were included in the review [Figure 1].Quality of the included studiesSummary of quality assessment of the included studies is reported in [Table 2]. Overall, nine studies were of poor quality, twenty were of moderate quality, and three studies were of high quality.

The CASP shows that out of the 32 studies, the sample size of 21 studies was not representative, sample size of 7 studies was not justified, risk factors were not identified in 28 studies, methods used were not sufficiently described to repeat them in 24 studies, and nonresponse reasons were not addressed in 24 studies. The most common reasons for studies to be of poor-quality included sample size not justified. Sample is not representative. Nonresponse not addressed. Risk factors not measured correctly.

And methods used were not sufficiently described to repeat them. Studies under the moderate quality did not have a representative sample. Non-responders categories was not addressed. Risk factors were not measured correctly. And methods used were not sufficiently described to allow the study to be replicated by other researchers.The included studies covered three broad categories.

Alcohol and substance use disorders, CMD (depression, anxiety, stress, and suicide risk), socio-cultural aspects, and access to mental health services.Alcohol and substance use disordersFive studies reviewed the consumption of alcohol and opioid. In an ethnographic study conducted in three western districts in Rajasthan, 200 opium users were interviewed. Opium consumption was common among both younger and older males during nonharvest seasons. The common causes for using opium were relief of anxiety related to crop failure due to drought, stress, to get a high, be part of peers, and for increased sexual performance.[16]In a study conducted in Arunachal Pradesh involving a population of more than 5000 individuals, alcohol use was present in 30% and opium use in about 5% adults.[17] Contrary to that study, in Rajasthan, the prevalence of opium use was more in women and socioeconomic factors such as occupation, education, and marital status were associated with opium use.[16] The prevalence of opium use increased with age in both sexes, decreased with increasing education level, and increased with employment. It was observed that wages were used to buy opium.

In the entire region of Chamlang district of Arunachal Pradesh, female substance users were almost half of the males among ST population.[17] Types of substance used were tobacco, alcohol, and opium. Among tobacco users, oral tobacco use was higher than smoking. The prevalence of tobacco use was higher among males, but the prevalence of alcohol use was higher in females, probably due to increased access to homemade rice brew generally prepared by women. This study is unique in terms of finding a strong association with religion and culture with substance use.[18]Alcohol consumption among Paniyas of Wayanad district in Kerala is perceived as a male activity, with many younger people consuming it than earlier. A study concluded that alcohol consumption among them was less of a “choice” than a result of their conditions operating through different mechanisms.

In the past, drinking was traditionally common among elderly males, however the consumption pattern has changed as a significant number of younger men are now drinking. Drinking was clustered within families as fathers and sons drank together. Alcohol is easily accessible as government itself provides opportunities. Some employers would provide alcohol as an incentive to attract Paniya men to work for them.[19]In a study from Jharkhand, several ST community members cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol. Societal acceptance of drinking alcohol and peer pressure, as well as high emotional problems, appeared to be the major etiology leading to higher prevalence of substance dependence in tribal communities.[20] Another study found high life time alcohol use prevalence, and the reasons mentioned were increased poverty, illiteracy, increased stress, and peer pressure.[21] A household survey from Chamlang district of Arunachal Pradesh revealed that there was a strong association between opium use and age, occupation, marital status, religion, and ethnicity among both the sexes of STs, particularly among Singhpho and Khamti.[15] The average age of onset of tobacco use was found to be 16.4 years for smoked and 17.5 years for smokeless forms in one study.[22]Common mental disorders and socio-cultural aspectsSuicide was more common among Idu Mishmi in Roing and Anini districts of Arunachal Pradesh state (14.2%) compared to the urban population in general (0.4%–4.2%).

Suicides were associated with depression, anxiety, alcoholism, and eating disorders. Of all the factors, depression was significantly high in people who attempted suicide.[24] About 5% out of 5007 people from thirty villages comprising ST suffered from CMDs in a study from West Godavari district in rural Andhra Pradesh. CMDs were defined as moderate/severe depression and/or anxiety, stress, and increased suicidal risk. Women had a higher prevalence of depression, but this may be due to the cultural norms, as men are less likely to express symptoms of depression or anxiety, which leads to underreporting. Marital status, education, and age were prominently associated with CMD.[14] In another study, gender, illiteracy, infant mortality in the household, having <3 adults living in the household, large family size with >four children, morbidity, and having two or more life events in the last year were associated with increased prevalence of CMD.[24] Urban and rural ST from the same community of Bhutias of Sikkim were examined, and it was found that the urban population experienced higher perceived stress compared to their rural counterparts.[25] Age, current use of alcohol, poor educational status, marital status, social groups, and comorbidities were the main determinants of tobacco use and nicotine dependence in a study from the Andaman and Nicobar Islands.[22] A study conducted among adolescents in the schools of rural areas of Ranchi district in Jharkhand revealed that about 5% children from the ST communities had emotional symptoms, 9.6% children had conduct problems, 4.2% had hyperactivity, and 1.4% had significant peer problems.[27] A study conducted among the female school teachers in Jharkhand examined the effects of stress, marital status, and ethnicity upon the mental health of school teachers.

The study found that among the three factors namely stress, marital status, and ethnicity, ethnicity was found to affect mental health of the school teachers most. It found a positive relationship between mental health and socioeconomic status, with an inverse relationship showing that as income increased, the prevalence of depression decreased.[28] A study among Ao-Nagas in Nagaland found that 74.6% of the population attributed mental health problems to psycho-social factors and a considerable proportion chose a psychiatrist or psychologist to overcome the problem. However, 15.4% attributed mental disorders to evil spirits. About 47% preferred to seek treatment with a psychiatrist and 25% preferred prayers. Nearly 10.6% wanted to seek the help of both the psychiatrist and prayer group and 4.4% preferred traditional healers.[28],[29] The prevalence of Down syndrome among the ST in Chikhalia in Barwani district of Madhya Pradesh was higher than that reported in overall India.

Three-fourth of the children were the first-born child. None of the parents of children with Down syndrome had consanguineous marriage or a history of Down syndrome, intellectual disability, or any other neurological disorder such as cerebral palsy and epilepsy in preceding generations. It is known that tribal population is highly impoverished and disadvantaged in several ways and suffer proportionately higher burden of nutritional and genetic disorders, which are potential factors for Down syndrome.[30]Access to mental health-care servicesIn a study in Ranchi district of Jharkhand, it was found that most people consulted faith healers rather than qualified medical practitioners. There are few mental health services in the regions.[31] Among ST population, there was less reliance and belief in modern medicine, and it was also not easily accessible, thus the health-care systems must be more holistic and take care of cultural and local health practices.[32]The Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health project was implemented in thirty ST villages in West Godavari District of Andhra Pradesh. The key objectives were to use task sharing, training of primary health workers, implementing evidence-based clinical decision support tools on a mobile platform, and providing mental health services to rural population.

The study included 238 adults suffering from CMD. During the intervention period, 12.6% visited the primary health-care doctors compared to only 0.8% who had sought any care for their mental disorders prior to the intervention. The study also found a significant reduction in the depression and anxiety scores at the end of intervention and improvements in stigma perceptions related to mental health.[14] A study in Gudalur and Pandalur Taluks of Nilgiri district from Tamil Nadu used low cost task shifting by providing community education and identifying and referring individuals with psychiatric problems as effective strategies for treating mental disorders in ST communities. Through the program, the health workers established a network within the village, which in turn helped the patients to interact with them freely. Consenting patients volunteered at the educational sessions to discuss their experience about the effectiveness of their treatment.

Community awareness programs altered knowledge and attitudes toward mental illness in the community.[33] A study in Nilgiri district, Tamil Nadu, found that the community had been taking responsibility of the patients with the system by providing treatment closer to home without people having to travel long distances to access care. Expenses were reduced by subsidizing the costs of medicine and ensuring free hospital admissions and referrals to the people.[34] A study on the impact of gender, socioeconomic status, and age on mental health of female factory workers in Jharkhand found that the ST women were more likely to face stress and hardship in life due to diverse economic and household responsibilities, which, in turn, severely affected their mental health.[35] Prevalence of mental health morbidity in a study from the Sunderbans delta found a positive relation with psycho-social stressors and poor quality of life. The health system in that remote area was largely managed by “quack doctors” and faith healers. Poverty, illiteracy, and detachment from the larger community helped reinforce superstitious beliefs and made them seek both mental and physical health care from faith healers.[36] In a study among students, it was found that children had difficulties in adjusting to both ethnic and mainstream culture.[27] Low family income, inadequate housing, poor sanitation, and unhealthy and unhygienic living conditions were some environmental factors contributing to poor physical and mental growth of children. It was observed that children who did not have such risk factors maintained more intimate relations with the family members.

Children belonging to the disadvantaged environment expressed their verbal, emotional need, blame, and harm avoidances more freely than their counterparts belonging to less disadvantaged backgrounds. Although disadvantaged children had poor interfamilial interaction, they had better relations with the members outside family, such as peers, friends, and neighbors.[37] Another study in Jharkhand found that epilepsy was higher among ST patients compared to non-ST patients.[31] Most patients among the ST are irregular and dropout rates are higher among them than the non-ST patients. Urbanization per se exerted no adverse influence on the mental health of a tribal community, provided it allowed preservation of ethnic and cultural practices. Women in the ST communities were less vulnerable to mental illness than men. This might be a reflection of their increased responsibilities and enhanced gender roles that are characteristic of women in many ST communities.[38] Data obtained using culturally relevant scales revealed that relocated Sahariya suffer a lot of mental health problems, which are partially explained by livelihood and poverty-related factors.

The loss of homes and displacement compromise mental health, especially the positive emotional well-being related to happiness, life satisfaction, optimism for future, and spiritual contentment. These are often not overcome even with good relocation programs focused on material compensation and livelihood re-establishment.[39] Discussion This systematic review is to our knowledge the first on mental health of ST population in India. Few studies on the mental health of ST were available. All attempts including hand searching were made to recover both published peer-reviewed papers and reports available on the website. Though we searched gray literature, it may be possible that it does not capture all articles.

Given the heterogeneity of the papers, it was not possible to do a meta-analysis, so a narrative review was done.The quality of the studies was assessed by CASP. The assessment shows that the research conducted on mental health of STs needs to be carried out more effectively. The above mentioned gaps need to be filled in future research by considering the resources effectively while conducting the studies. Mental and substance use disorders contribute majorly to the health disparities. To address this, one needs to deliver evidence-based treatments, but it is important to understand how far these interventions for the indigenous populations can incorporate cultural practices, which are essential for the development of mental health services.[30] Evidence has shown a disproportionate burden of suicide among indigenous populations in national and regional studies, and a global and systematic investigation of this topic has not been undertaken to date.

Previous reviews of suicide epidemiology among indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth, high-income countries, or regions such as Oceania or the Arctic.[46] The only studies in our review which provided data on suicide were in Idu Mishmi, an isolated tribal population of North-East India, and tribal communities from Sunderban delta.[24],[37] Some reasons for suicide in these populations could be the poor identification of existing mental disorders, increased alcohol use, extreme poverty leading to increased debt and hopelessness, and lack of stable employment opportunities.[24],[37] The traditional consumption pattern of alcohol has changed due to the reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement.[19],[20]Faith healers play a dominant role in treating mental disorders. There is less awareness about mental health and available mental health services and even if such knowledge is available, access is limited due to remoteness of many of these villages, and often it involves high out-of-pocket expenditure.[35] Practitioners of modern medicine can play a vital role in not only increasing awareness about mental health in the community, but also engaging with faith healers and traditional medicine practitioners to help increase their capacity to identify and manage CMDs that do not need medications and can be managed through simple “talk therapy.” Knowledge on symptoms of severe mental disorders can also help such faith healers and traditional medicine practitioners to refer cases to primary care doctors or mental health professionals.Remote settlements make it difficult for ST communities to seek mental health care. Access needs to be increased by using solutions that use training of primary health workers and nonphysician health workers, task sharing, and technology-enabled clinical decision support tools.[3] The SMART Mental Health project was delivered in the tribal areas of Andhra Pradesh using those principles and was found to be beneficial by all stakeholders.[14]Given the lack of knowledge about mental health problems among these communities, the government and nongovernmental organizations should collect and disseminate data on mental disorders among the ST communities. More research funding needs to be provided and key stakeholders should be involved in creating awareness both in the community and among policy makers to develop more projects for ST communities around mental health. Two recent meetings on tribal mental health – Round Table Meeting on Mental Health of ST Populations organized by the George Institute for Global Health, India, in 2017,[51] and the First National Conference on Tribal Mental Health organized by the Indian Psychiatric Society in Bhubaneswar in 2018 – have identified some key areas of research priority for mental health in ST communities.

A national-level policy on mental health of tribal communities or population is advocated which should be developed in consultation with key stakeholders. The Indian Psychiatric Society can play a role in coordinating research activities with support of the government which can ensure regular monitoring and dissemination of the research impact to the tribal communities. There is a need to understand how mental health symptoms are perceived in different ST communities and investigate the healing practices associated with distress/disaster/death/loss/disease. This could be done in the form of cross-sectional or cohort studies to generate proper evidence which could also include the information on prevalence, mental health morbidity, and any specific patterns associated with a specific disorder. Future research should estimate the prevalence of mental disorders in different age groups and gender, risk factors, and the influence of modernization.

Studies should develop a theoretical model to understand mental disorders and promote positive mental health within ST communities. Studies should also look at different ST communities as cultural differences exist across them, and there are also differences in socioeconomic status which impact on ability to access care.Research has shown that the impact and the benefits are amplified when research is driven by priorities that are identified by indigenous communities and involve their active participation. Their knowledge and perspectives are incorporated in processes and findings. Reporting of findings is meaningful to the communities. And indigenous groups and other key stakeholders are engaged from the outset.[47] Future research in India on ST communities should also adhere to these broad principles to ensure relevant and beneficial research, which have direct impact on the mental health of the ST communities.There is also a need to update literature related to mental health of ST population continuously.

Develop culturally appropriate validated instruments to measure mental morbidity relevant to ST population. And use qualitative research to investigate the perceptions and barriers for help-seeking behavior.[48] Conclusion The current review helps not only to collate the existing literature on the mental health of ST communities but also identify gaps in knowledge and provide some indications about the type of research that should be funded in future.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Gururaj G, Girish N, Isaac MK. Mental. Neurological and Substance abuse disorders.

Strategies towards a systems approach. In. Burden of Disease in India. Equitable development – Healthy future New Delhi, India. National Commission on Macroeconomics and Health.

Ministry of Health and Family Welfare, Government of India. 2005. 2.Math SB, Srinivasaraju R. Indian Psychiatric epidemiological studies. Learning from the past.

Indian J Psychiatry 2010;52:S95-103. 3.Tewari A, Kallakuri S, Devarapalli S, Jha V, Patel A, Maulik PK. Process evaluation of the systematic medical appraisal, referral and treatment (SMART) mental health project in rural India. BMC Psychiatry 2017;17:385. 4.Ministry of Tribal Affairs, Government of India.

Report of the High Level Committee on Socio-economic, Health and Educational Status of Tribal Communities of India. New Delhi. Government of India. 2014. 5.Office of the Registrar General and Census Commissioner, Census of India.

New Delhi. Office of the Registrar General and Census Commissioner. 2011. 6.International Institute for Population Sciences and ICF. National Family Health Survey (NFHS-4), 2015-16.

India, Mumbai. International Institute for Population Sciences. 2017. 7.World Health Organization. The World Health Report 2001-Mental Health.

New Understanding, New Hope. Geneva, Switzerland. World Health Organization. 2001. 8.Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, et al.

Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004;291:2581-90. 9.Ministry of Health and Family Welfare, Government of India and Ministry of Tribal Affairs, Report of the Expert Committee on Tribal Health. Tribal Health in India – Bridging the Gap and a Roadmap for the Future. New Delhi.

Government of India. 2013. 10.Government of India, Rural Health Statistics 2016-17. Ministry of Health and Family Welfare Statistics Division. 2017.

11.Ormel J, VonKorff M, Ustun TB, Pini S, Korten A, Oldehinkel T. Common mental disorders and disability across cultures. Results from the WHO Collaborative Study on Psychological Problems in General Health Care. JAMA 1994;272:1741-8. 12.Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, INDIGO Study Group.

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Impact on knowledge and attitudes. Int J Ment Health Syst 2011;5:17. 14.Maulik PK, Kallakuri S, Devarapalli S, Vadlamani VS, Jha V, Patel A. Increasing use of mental health services in remote areas using mobile technology. A pre-post evaluation of the SMART Mental Health project in rural India.

J Global Health 2017;7:1-13. 15.16.Ganguly KK, Sharma HK, Krishnamachari KA. An ethnographic account of opium consumers of Rajasthan (India). Socio-medical perspective. Addiction 1995;90:9-12.

17.Chaturvedi HK, Mahanta J. Sociocultural diversity and substance use pattern in Arunachal Pradesh, India. Drug Alcohol Depend 2004;74:97-104. 18.Chaturvedi HK, Mahanta J, Bajpai RC, Pandey A. Correlates of opium use.

Retrospective analysis of a survey of tribal communities in Arunachal Pradesh, India. BMC Public Health 2013;13:325. 19.Mohindra KS, Narayana D, Anushreedha SS, Haddad S. Alcohol use and its consequences in South India. Views from a marginalised tribal population.

Drug Alcohol Depend 2011;117:70-3. 20.Sreeraj VS, Prasad S, Khess CR, Uvais NA. Reasons for substance use. A comparative study of alcohol use in tribals and non-tribals. Indian J Psychol Med 2012;34:242-6.

[PUBMED] [Full text] 21.Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders. Findings from the Global Burden of Disease Study 2010. Lancet 2013;382:1575-86. 22.Janakiram C, Joseph J, Vasudevan S, Taha F, DeepanKumar CV, Venkitachalam R.

Prevalence and dependancy of tobacco use in an indigenous population of Kerala, India. Oral Hygiene and Health 2016;4:1 23.Manimunda SP, Benegal V, Sugunan AP, Jeemon P, Balakrishna N, Thennarusu K, et al. Tobacco use and nicotine dependency in a cross-sectional representative sample of 18,018 individuals in Andaman and Nicobar Islands, India. BMC Public Health 2012;12:515. 24.Singh PK, Singh RK, Biswas A, Rao VR.

High rate of suicide attempt and associated psychological traits in an isolated tribal population of North-East India. J Affect Dis 2013;151:673-8. 25.Sushila J. Perception of Illness and Health Care among Bhils. A Study of Udaipur District in Southern Rajasthan.

2005. 26.Sobhanjan S, Mukhopadhyay B. Perceived psychosocial stress and cardiovascular risk. Observations among the Bhutias of Sikkim, India. Stress Health 2008;24:23-34.

27.Ali A, Eqbal S. Mental Health status of tribal school going adolescents. A study from rural community of Ranchi, Jharkhand. Telangana J Psychiatry 2016;2:38-41. 28.Diwan R.

Stress and mental health of tribal and non tribal female school teachers in Jharkhand, India. Int J Sci Res Publicat 2012;2:2250-3153. 29.Longkumer I, Borooah PI. Knowledge about attitudes toward mental disorders among Nagas in North East India. IOSR J Humanities Soc Sci 2013;15:41-7.

30.Lakhan R, Kishore MT. Down syndrome in tribal population in India. A field observation. J Neurosci Rural Pract 2016;7:40-3. [PUBMED] [Full text] 31.Nizamie HS, Akhtar S, Banerjee S, Goyal N.

Health care delivery model in epilepsy to reduce treatment gap. WHO study from a rural tribal population of India. Epilepsy Res Elsevier 2009;84:146-52. 32.Prabhakar H, Manoharan R. The Tribal Health Initiative model for healthcare delivery.

A clinical and epidemiological approach. Natl Med J India 2005;18:197-204. 33.Nimgaonkar AU, Menon SD. A task shifting mental health program for an impoverished rural Indian community. Asian J Psychiatr 2015;16:41-7.

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Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India. A cluster-randomised controlled trial. Lancet 2010;375:1182-92. 36.Aparajita C, Anita KM, Arundhati R, Chetana P. Assessing Social-support network among the socio culturally disadvantaged children in India.

Early Child Develop Care 1996;121:37-47. 37.Chowdhury AN, Mondal R, Brahma A, Biswas MK. Eco-psychiatry and environmental conservation. Study from Sundarban Delta, India. Environ Health Insights 2008;2:61-76.

38.Jeffery GS, Chakrapani U. Eco-psychiatry and Environmental Conservation. Study from Sundarban Delta, India. Working Paper- Research Gate.net. September, 2016.

39.Ozer S, Acculturation, adaptation, and mental health among Ladakhi College Students a mixed methods study of an indigenous population. J Cross Cultl Psychol 2015;46:435-53. 40.Giri DK, Chaudhary S, Govinda M, Banerjee A, Mahto AK, Chakravorty PK. Utilization of psychiatric services by tribal population of Jharkhand through community outreach programme of RINPAS. Eastern J Psychiatry 2007;10:25-9.

41.Nandi DN, Banerjee G, Chowdhury AN, Banerjee T, Boral GC, Sen B. Urbanization and mental morbidity in certain tribal communities in West Bengal. Indian J Psychiatry 1992;34:334-9. [PUBMED] [Full text] 42.Hackett RJ, Sagdeo D, Creed FH. The physical and social associations of common mental disorder in a tribal population in South India.

Soc Psychiatry Psychiatr Epidemiol 2007;42:712-5. 43.Raina SK, Raina S, Chander V, Grover A, Singh S, Bhardwaj A. Development of a cognitive screening instrument for tribal elderly population of Himalayan region in northern India. J Neurosci Rural Pract 2013;4:147-53. [PUBMED] [Full text] 44.Raina SK, Raina S, Chander V, Grover A, Singh S, Bhardwaj A.

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Evaluation of the Cooperative Research Centre for Aboriginal Health (Australian institute for primary care, trans.). Melbourne. LaTrobe University. 2010. 51.

Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].

How to buy 250mg amoxil online cite this who can buy amoxil article:Singh OP. Psychiatry research in India. Closing the buy 250mg amoxil online research gap. Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science. Research in buy 250mg amoxil online India in general and medical research in particular is always being criticized for lack of innovation and originality required for the delivery of health services suitable to Indian conditions.

Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list buy 250mg amoxil online one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up to the mark and is not commensurate with the magnitude of the disease burden in India. According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases. The research conducted elsewhere may buy 250mg amoxil online not be generalized to the Indian population owing to differences in biology, health-care systems, health practices, culture, and socioeconomic standards.

Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017–2018) of the Department of Health Research observed that “the biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.”[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research. While ICMR has a budget of 232 million dollars per year on health research, it is zilch in comparison to the annual budget expenditure of the National Institute of Health, USA, buy 250mg amoxil online on biomedical research which is 32 billion dollars.The lacuna of quality research is not merely due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic buy 250mg amoxil online intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical institutions.

The majority of these are done as thesis submission for fulfillment of the requirement of PG degree. From 2015 onward, publication of buy 250mg amoxil online papers had been made an obligatory requirement for promotion of faculty to higher posts. Although it offered a unique opportunity for training of residents and stimulus for research, it failed to translate into production of quality research work as thesis was limited by time and it had to be done with other clinical and academic duties.While the top four medical colleges, namely AIIMS, New Delhi. PGIMER, Chandigarh. CMC, Vellore buy 250mg amoxil online.

And SGIMS, Lucknow are among the top ten medical institutions in terms of publication in peer-reviewed journals, around 332 (57.3%) medical colleges have no research paper published in a decade between 2004 and 2014.[2]The research in psychiatry is realistically dominated by major research institutes which are doing commendable work, but there is a substantial lack of contemporary research originating from other centers. Dr. Chittaranjan Andrade (NIMHANS, Bengaluru) and Dr. K Jacob (CMC, Vellore) recently figured in the list of top 2% psychiatry researchers in the world from India in psychiatry.[3] Most of the research conducted in the field of psychiatry are limited to caregivers' burden, pathways of care, and other topics which can be done in limited resources available to psychiatry departments. While all these areas of work are important in providing proper care and treatment, there is overabundance of research in these areas.The Government of India is aggressively looking forward to enhancing the quality of research and is embarking on an ambitious project of purchasing all major journals and providing free access to universities across the country.

The India Genome Project started in January, 2020, is a good example of collaboration. While all these actions are laudable, a lot more needs to be done. Following are some measures which will reduce the gap:Research proposals at the level of protocol can be guided and mentored by institutes. Academic committees of different zones and journals can help in this endeavorBreaking the cubicles by establishing a collaboration between medical colleges and various institutes. While there is a lack of resources available in individual departments, there are universities and institutes with excellent infrastructure.

They are not aware of the requirements of the field of psychiatry and research questions. Creation of an alliance will enhance the quality of research work. Some of such institutes include Centre for Neuroscience, Indian Institute of Science, Bengaluru. CSIR-Institute of Genomics and Integrative Biology, New Delhi. And National Institute of Biomedical Genomics, KalyaniInitiation and establishment of interactive and stable relationships between basic scientists and clinical and technological experts will enhance the quality of research work and will lead to translation of basic biomedical research into real-time applications.

For example, work on artificial intelligence for mental health. Development of Apps by IITs. Genome India Project by the Government of India, genomic institutes, and social science and economic institutes working in the field of various aspects of mental healthUtilization of underutilized, well-equipped biotechnological labs of nonmedical colleges for furthering biomedical researchMedical colleges should collaborate with various universities which have labs providing testing facilities such as spectroscopy, fluoroscopy, gamma camera, scintigraphy, positron emission tomography, single photon emission computed tomography, and photoacoustic imagingCreating an interactive, interdepartmental, intradepartmental, and interinstitutional partnershipBy developing a healthy and ethical partnership with industries for research and development of new drugs and interventions.Walking the talk – the psychiatric fraternity needs to be proactive and rather than lamenting about the lack of resource, we should rise to the occasion and come out with innovative and original research proposals. With the implementation of collaborative approach, we can not only enhance and improve the quality of our research but to an extent also mitigate the effects of resource crunch and come up as a leader in the field of biomedical research. References 1.2.Nagoba B, Davane M.

Current status of medical research in India. Where are we?. Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J. Updated science-wide author databases of standardized citation indicators.

PLoS Biol 2020;18:e3000918. Correspondence Address:Dr. Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/indianjpsychiatry.indianjpsychiatry_1362_2Abstract Background. The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly.Aim. The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research.Materials and Methods. Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis. PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies.

Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme. Studies were summarized and reported descriptively.Results. Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas. Alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services.

Sociocultural factors play a major role in understanding and determining mental disorders.Conclusion. This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality. Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.Keywords. India, mental health, scheduled tribesHow to cite this article:Devarapalli S V, Kallakuri S, Salam A, Maulik PK.

Mental health research on scheduled tribes in India. Indian J Psychiatry 2020;62:617-30 Introduction Mental health is a highly neglected area particularly in low and middle-income countries (LMIC). Data from community-based studies showed that about 10% of people suffer from common mental disorders (CMDs) such as depression, anxiety, and somatic complaints.[1] A systematic review of epidemiological studies between 1960 and 2009 in India reported that about 20% of the adult population in the community are affected by psychiatric disorders in the community, ranging from 9.5 to 103/1000 population, with differences in case definitions, and methods of data collection, accounting for most of the variation in estimates.[2]The scheduled tribes (ST) population is a marginalized community and live in relative social isolation with poorer health indices compared to similar nontribal populations.[3] There are an estimated 90 million STs or Adivasis in India.[4] They constitute 8.6% of the total Indian population. The distribution varies across the states and union territories of India, with the highest percentage in Lakshadweep (94.8%) followed by Mizoram (94.4%). In northeastern states, they constitute 65% or more of the total population.[5] The ST communities are identified as culturally or ethnographically unique by the Indian Constitution.

They are populations with poorer health indicators and fewer health-care facilities compared to non-ST rural populations, even when within the same state, and often live in demarcated geographical areas known as ST areas.[4]As per the National Family Health Survey, 2015–2016, the health indicators such as infant mortality rate (IMR) is 44.4, under five mortality rate (U5MR) is 57.2, and anemia in women is 59.8 for STs – one of the most disadvantaged socioeconomic groups in India, which are worse compared to other populations where IMR is 40.7, U5MR is 49.7, and anemia in women among others is 53.0 in the same areas.[6] Little research is available on the health of ST population. Tribal mental health is an ignored and neglected area in the field of health-care services. Further, little data are available about the burden of mental disorders among the tribal communities. Health research on tribal populations is poor, globally.[7] Irrespective of the data available, it is clear that they have worse health indicators and less access to health facilities.[8] Even less is known about the burden of mental disorders in ST population. It is also found that the traditional livelihood system of the STs came into conflict with the forces of modernization, resulting not only in the loss of customary rights over the livelihood resources but also in subordination and further, developing low self-esteem, causing great psychological stress.[4] This community has poor health infrastructure and even less mental health resources, and the situation is worse when compared to other communities living in similar areas.[9],[10]Only 15%–25% of those affected with mental disorders in LMICs receive any treatment for their mental illness,[11] resulting in a large “treatment gap.”[12] Treatment gaps are more in rural populations,[13] especially in ST communities in India, which have particularly poor infrastructure and resources for health-care delivery in general, and almost no capacity for providing mental health care.[14]The aim of this systematic review was to explore the extent and nature of mental health research on ST population in India and to identify gaps and inform future research.

Materials and Methods Search strategyWe searched major databases (PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar) and made hand searches from January 1980 to December 2018 to identify relevant literature. Hand search refers to searching through medical journals which are not indexed in the major electronic databases such as Embase, for instance, searching for Indian journals in IndMed database as most of these journals are not available in major databases. Physical search refers to searching the journals that were not available online or were not available online during the study years. We used relevant Medical Subject Heading and key terms in our search strategy, as follows. €œMental health,” “Mental disorders,” “Mental illness,” “Psychiatry,” “Scheduled Tribe” OR “Tribe” OR “Tribal Population” OR “Indigenous population,” “India,” “Psych*” (Psychiatric, psychological, psychosis).Inclusion criteriaStudies published between January 1980 and December 2018 were included.

Studies on mental disorders were included only when they focused on ST population. Both qualitative and quantitative studies on mental disorders of ST population only were included in the analysis.Exclusion criteriaStudies without any primary data and which are merely overviews and commentaries and those not focused on ST population were excluded from the analysis.Data management and analysisTwo researchers (SD and SK) initially screened the title and abstract of each record to identify relevant papers and subsequently screened full text of those relevant papers. Any disagreements between the researchers were resolved by discussion or by consulting with an adjudicator (PKM). From each study, data were extracted on objectives, study design, study population, study duration, interventions (if applicable), outcomes, and results. Quality of the included studies was assessed, independently by three researchers (SD, SK, and AS), using Critical Appraisal Checklist developed by Critical Appraisal Skills Programme (CASP).[15] After a thorough qualitative assessment, all quantitative data were generated and tabulated.

A narrative description of the studies is provided in [Table 1] using some broad categories. Results Search resultsOur search retrieved 2306 records (which included hand-searched articles), of which after removing duplicates, title and abstracts of 2278 records were screened. Of these, 178 studies were deemed as potentially relevant and were reviewed in detail. Finally, we excluded 146 irrelevant studies and 32 studies were included in the review [Figure 1].Quality of the included studiesSummary of quality assessment of the included studies is reported in [Table 2]. Overall, nine studies were of poor quality, twenty were of moderate quality, and three studies were of high quality.

The CASP shows that out of the 32 studies, the sample size of 21 studies was not representative, sample size of 7 studies was not justified, risk factors were not identified in 28 studies, methods used were not sufficiently described to repeat them in 24 studies, and nonresponse reasons were not addressed in 24 studies. The most common reasons for studies to be of poor-quality included sample size not justified. Sample is not representative. Nonresponse not addressed. Risk factors not measured correctly.

And methods used were not sufficiently described to repeat them. Studies under the moderate quality did not have a representative sample. Non-responders categories was not addressed. Risk factors were not measured correctly. And methods used were not sufficiently described to allow the study to be replicated by other researchers.The included studies covered three broad categories.

Alcohol and substance use disorders, CMD (depression, anxiety, stress, and suicide risk), socio-cultural aspects, and access to mental health services.Alcohol and substance use disordersFive studies reviewed the consumption of alcohol and opioid. In an ethnographic study conducted in three western districts in Rajasthan, 200 opium users were interviewed. Opium consumption was common among both younger and older males during nonharvest seasons. The common causes for using opium were relief of anxiety related to crop failure due to drought, stress, to get a high, be part of peers, and for increased sexual performance.[16]In a study conducted in Arunachal Pradesh involving a population of more than 5000 individuals, alcohol use was present in 30% and opium use in about 5% adults.[17] Contrary to that study, in Rajasthan, the prevalence of opium use was more in women and socioeconomic factors such as occupation, education, and marital status were associated with opium use.[16] The prevalence of opium use increased with age in both sexes, decreased with increasing education level, and increased with employment. It was observed that wages were used to buy opium.

In the entire region of Chamlang district of Arunachal Pradesh, female substance users were almost half of the males among ST population.[17] Types of substance used were tobacco, alcohol, and opium. Among tobacco users, oral tobacco use was higher than smoking. The prevalence of tobacco use was higher among males, but the prevalence of alcohol use was higher in females, probably due to increased access to homemade rice brew generally prepared by women. This study is unique in terms of finding a strong association with religion and culture with substance use.[18]Alcohol consumption among Paniyas of Wayanad district in Kerala is perceived as a male activity, with many younger people consuming it than earlier. A study concluded that alcohol consumption among them was less of a “choice” than a result of their conditions operating through different mechanisms.

In the past, drinking was traditionally common among elderly males, however the consumption pattern has changed as a significant number of younger men are now drinking. Drinking was clustered within families as fathers and sons drank together. Alcohol is easily accessible as government itself provides opportunities. Some employers would provide alcohol as an incentive to attract Paniya men to work for them.[19]In a study from Jharkhand, several ST community members cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol. Societal acceptance of drinking alcohol and peer pressure, as well as high emotional problems, appeared to be the major etiology leading to higher prevalence of substance dependence in tribal communities.[20] Another study found high life time alcohol use prevalence, and the reasons mentioned were increased poverty, illiteracy, increased stress, and peer pressure.[21] A household survey from Chamlang district of Arunachal Pradesh revealed that there was a strong association between opium use and age, occupation, marital status, religion, and ethnicity among both the sexes of STs, particularly among Singhpho and Khamti.[15] The average age of onset of tobacco use was found to be 16.4 years for smoked and 17.5 years for smokeless forms in one study.[22]Common mental disorders and socio-cultural aspectsSuicide was more common among Idu Mishmi in Roing and Anini districts of Arunachal Pradesh state (14.2%) compared to the urban population in general (0.4%–4.2%).

Suicides were associated with depression, anxiety, alcoholism, and eating disorders. Of all the factors, depression was significantly high in people who attempted suicide.[24] About 5% out of 5007 people from thirty villages comprising ST suffered from CMDs in a study from West Godavari district in rural Andhra Pradesh. CMDs were defined as moderate/severe depression and/or anxiety, stress, and increased suicidal risk. Women had a higher prevalence of depression, but this may be due to the cultural norms, as men are less likely to express symptoms of depression or anxiety, which leads to underreporting. Marital status, education, and age were prominently associated with CMD.[14] In another study, gender, illiteracy, infant mortality in the household, having <3 adults living in the household, large family size with >four children, morbidity, and having two or more life events in the last year were associated with increased prevalence of CMD.[24] Urban and rural ST from the same community of Bhutias of Sikkim were examined, and it was found that the urban population experienced higher perceived stress compared to their rural counterparts.[25] Age, current use of alcohol, poor educational status, marital status, social groups, and comorbidities were the main determinants of tobacco use and nicotine dependence in a study from the Andaman and Nicobar Islands.[22] A study conducted among adolescents in the schools of rural areas of Ranchi district in Jharkhand revealed that about 5% children from the ST communities had emotional symptoms, 9.6% children had conduct problems, 4.2% had hyperactivity, and 1.4% had significant peer problems.[27] A study conducted among the female school teachers in Jharkhand examined the effects of stress, marital status, and ethnicity upon the mental health of school teachers.

The study found that among the three factors namely stress, marital status, and ethnicity, ethnicity was found to affect mental health of the school teachers most. It found a positive relationship between mental health and socioeconomic status, with an inverse relationship showing that as income increased, the prevalence of depression decreased.[28] A study among Ao-Nagas in Nagaland found that 74.6% of the population attributed mental health problems to psycho-social factors and a considerable proportion chose a psychiatrist or psychologist to overcome the problem. However, 15.4% attributed mental disorders to evil spirits. About 47% preferred to seek treatment with a psychiatrist and 25% preferred prayers. Nearly 10.6% wanted to seek the help of both the psychiatrist and prayer group and 4.4% preferred traditional healers.[28],[29] The prevalence of Down syndrome among the ST in Chikhalia in Barwani district of Madhya Pradesh was higher than that reported in overall India.

Three-fourth of the children were the first-born child. None of the parents of children with Down syndrome had consanguineous marriage or a history of Down syndrome, intellectual disability, or any other neurological disorder such as cerebral palsy and epilepsy in preceding generations. It is known that tribal population is highly impoverished and disadvantaged in several ways and suffer proportionately higher burden of nutritional and genetic disorders, which are potential factors for Down syndrome.[30]Access to mental health-care servicesIn a study in Ranchi district of Jharkhand, it was found that most people consulted faith healers rather than qualified medical practitioners. There are few mental health services in the regions.[31] Among ST population, there was less reliance and belief in modern medicine, and it was also not easily accessible, thus the health-care systems must be more holistic and take care of cultural and local health practices.[32]The Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health project was implemented in thirty ST villages in West Godavari District of Andhra Pradesh. The key objectives were to use task sharing, training of primary health workers, implementing evidence-based clinical decision support tools on a mobile platform, and providing mental health services to rural population.

The study included 238 adults suffering from CMD. During the intervention period, 12.6% visited the primary health-care doctors compared to only 0.8% who had sought any care for their mental disorders prior to the intervention. The study also found a significant reduction in the depression and anxiety scores at the end of intervention and improvements in stigma perceptions related to mental health.[14] A study in Gudalur and Pandalur Taluks of Nilgiri district from Tamil Nadu used low cost task shifting by providing community education and identifying and referring individuals with psychiatric problems as effective strategies for treating mental disorders in ST communities. Through the program, the health workers established a network within the village, which in turn helped the patients to interact with them freely. Consenting patients volunteered at the educational sessions to discuss their experience about the effectiveness of their treatment.

Community awareness programs altered knowledge and attitudes toward mental illness in the community.[33] A study in Nilgiri district, Tamil Nadu, found that the community had been taking responsibility of the patients with the system by providing treatment closer to home without people having to travel long distances to access care. Expenses were reduced by subsidizing the costs of medicine and ensuring free hospital admissions and referrals to the people.[34] A study on the impact of gender, socioeconomic status, and age on mental health of female factory workers in Jharkhand found that the ST women were more likely to face stress and hardship in life due to diverse economic and household responsibilities, which, in turn, severely affected their mental health.[35] Prevalence of mental health morbidity in a study from the Sunderbans delta found a positive relation with psycho-social stressors and poor quality of life. The health system in that remote area was largely managed by “quack doctors” and faith healers. Poverty, illiteracy, and detachment from the larger community helped reinforce superstitious beliefs and made them seek both mental and physical health care from faith healers.[36] In a study among students, it was found that children had difficulties in adjusting to both ethnic and mainstream culture.[27] Low family income, inadequate housing, poor sanitation, and unhealthy and unhygienic living conditions were some environmental factors contributing to poor physical and mental growth of children. It was observed that children who did not have such risk factors maintained more intimate relations with the family members.

Children belonging to the disadvantaged environment expressed their verbal, emotional need, blame, and harm avoidances more freely than their counterparts belonging to less disadvantaged backgrounds. Although disadvantaged children had poor interfamilial interaction, they had better relations with the members outside family, such as peers, friends, and neighbors.[37] Another study in Jharkhand found that epilepsy was higher among ST patients compared to non-ST patients.[31] Most patients among the ST are irregular and dropout rates are higher among them than the non-ST patients. Urbanization per se exerted no adverse influence on the mental health of a tribal community, provided it allowed preservation of ethnic and cultural practices. Women in the ST communities were less vulnerable to mental illness than men. This might be a reflection of their increased responsibilities and enhanced gender roles that are characteristic of women in many ST communities.[38] Data obtained using culturally relevant scales revealed that relocated Sahariya suffer a lot of mental health problems, which are partially explained by livelihood and poverty-related factors.

The loss of homes and displacement compromise mental health, especially the positive emotional well-being related to happiness, life satisfaction, optimism for future, and spiritual contentment. These are often not overcome even with good relocation programs focused on material compensation and livelihood re-establishment.[39] Discussion This systematic review is to our knowledge the first on mental health of ST population in India. Few studies on the mental health of ST were available. All attempts including hand searching were made to recover both published peer-reviewed papers and reports available on the website. Though we searched gray literature, it may be possible that it does not capture all articles.

Given the heterogeneity of the papers, it was not possible to do a meta-analysis, so a narrative review was done.The quality of the studies was assessed by CASP. The assessment shows that the research conducted on mental health of STs needs to be carried out more effectively. The above mentioned gaps need to be filled in future research by considering the resources effectively while conducting the studies. Mental and substance use disorders contribute majorly to the health disparities. To address this, one needs to deliver evidence-based treatments, but it is important to understand how far these interventions for the indigenous populations can incorporate cultural practices, which are essential for the development of mental health services.[30] Evidence has shown a disproportionate burden of suicide among indigenous populations in national and regional studies, and a global and systematic investigation of this topic has not been undertaken to date.

Previous reviews of suicide epidemiology among indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth, high-income countries, or regions such as Oceania or the Arctic.[46] The only studies in our review which provided data on suicide were in Idu Mishmi, an isolated tribal population of North-East India, and tribal communities from Sunderban delta.[24],[37] Some reasons for suicide in these populations could be the poor identification of existing mental disorders, increased alcohol use, extreme poverty leading to increased debt and hopelessness, and lack of stable employment opportunities.[24],[37] The traditional consumption pattern of alcohol has changed due to the reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement.[19],[20]Faith healers play a dominant role in treating mental disorders. There is less awareness about mental health and available mental health services and even if such knowledge is available, access is limited due to remoteness of many of these villages, and often it involves high out-of-pocket expenditure.[35] Practitioners of modern medicine can play a vital role in not only increasing awareness about mental health in the community, but also engaging with faith healers and traditional medicine practitioners to help increase their capacity to identify and manage CMDs that do not need medications and can be managed through simple “talk therapy.” Knowledge on symptoms of severe mental disorders can also help such faith healers and traditional medicine practitioners to refer cases to primary care doctors or mental health professionals.Remote settlements make it difficult for ST communities to seek mental health care. Access needs to be increased by using solutions that use training of primary health workers and nonphysician health workers, task sharing, and technology-enabled clinical decision support tools.[3] The SMART Mental Health project was delivered in the tribal areas of Andhra Pradesh using those principles and was found to be beneficial by all stakeholders.[14]Given the lack of knowledge about mental health problems among these communities, the government and nongovernmental organizations should collect and disseminate data on mental disorders among the ST communities. More research funding needs to be provided and key stakeholders should be involved in creating awareness both in the community and among policy makers to develop more projects for ST communities around mental health. Two recent meetings on tribal mental health – Round Table Meeting on Mental Health of ST Populations organized by the George Institute for Global Health, India, in 2017,[51] and the First National Conference on Tribal Mental Health organized by the Indian Psychiatric Society in Bhubaneswar in 2018 – have identified some key areas of research priority for mental health in ST communities.

A national-level policy on mental health of tribal communities or population is advocated which should be developed in consultation with key stakeholders. The Indian Psychiatric Society can play a role in coordinating research activities with support of the government which can ensure regular monitoring and dissemination of the research impact to the tribal communities. There is a need to understand how mental health symptoms are perceived in different ST communities and investigate the healing practices associated with distress/disaster/death/loss/disease. This could be done in the form of cross-sectional or cohort studies to generate proper evidence which could also include the information on prevalence, mental health morbidity, and any specific patterns associated with a specific disorder. Future research should estimate the prevalence of mental disorders in different age groups and gender, risk factors, and the influence of modernization.

Studies should develop a theoretical model to understand mental disorders and promote positive mental health within ST communities. Studies should also look at different ST communities as cultural differences exist across them, and there are also differences in socioeconomic status which impact on ability to access care.Research has shown that the impact and the benefits are amplified when research is driven by priorities that are identified by indigenous communities and involve their active participation. Their knowledge and perspectives are incorporated in processes and findings. Reporting of findings is meaningful to the communities. And indigenous groups and other key stakeholders are engaged from the outset.[47] Future research in India on ST communities should also adhere to these broad principles to ensure relevant and beneficial research, which have direct impact on the mental health of the ST communities.There is also a need to update literature related to mental health of ST population continuously.

Develop culturally appropriate validated instruments to measure mental morbidity relevant to ST population. And use qualitative research to investigate the perceptions and barriers for help-seeking behavior.[48] Conclusion The current review helps not only to collate the existing literature on the mental health of ST communities but also identify gaps in knowledge and provide some indications about the type of research that should be funded in future.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Gururaj G, Girish N, Isaac MK. Mental. Neurological and Substance abuse disorders.

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Impact on knowledge and attitudes. Int J Ment Health Syst 2011;5:17. 14.Maulik PK, Kallakuri S, Devarapalli S, Vadlamani VS, Jha V, Patel A. Increasing use of mental health services in remote areas using mobile technology. A pre-post evaluation of the SMART Mental Health project in rural India.

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2005. 26.Sobhanjan S, Mukhopadhyay B. Perceived psychosocial stress and cardiovascular risk. Observations among the Bhutias of Sikkim, India. Stress Health 2008;24:23-34.

27.Ali A, Eqbal S. Mental Health status of tribal school going adolescents. A study from rural community of Ranchi, Jharkhand. Telangana J Psychiatry 2016;2:38-41. 28.Diwan R.

Stress and mental health of tribal and non tribal female school teachers in Jharkhand, India. Int J Sci Res Publicat 2012;2:2250-3153. 29.Longkumer I, Borooah PI. Knowledge about attitudes toward mental disorders among Nagas in North East India. IOSR J Humanities Soc Sci 2013;15:41-7.

30.Lakhan R, Kishore MT. Down syndrome in tribal population in India. A field observation. J Neurosci Rural Pract 2016;7:40-3. [PUBMED] [Full text] 31.Nizamie HS, Akhtar S, Banerjee S, Goyal N.

Health care delivery model in epilepsy to reduce treatment gap. WHO study from a rural tribal population of India. Epilepsy Res Elsevier 2009;84:146-52. 32.Prabhakar H, Manoharan R. The Tribal Health Initiative model for healthcare delivery.

A clinical and epidemiological approach. Natl Med J India 2005;18:197-204. 33.Nimgaonkar AU, Menon SD. A task shifting mental health program for an impoverished rural Indian community. Asian J Psychiatr 2015;16:41-7.

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Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India. A cluster-randomised controlled trial. Lancet 2010;375:1182-92. 36.Aparajita C, Anita KM, Arundhati R, Chetana P. Assessing Social-support network among the socio culturally disadvantaged children in India.

Early Child Develop Care 1996;121:37-47. 37.Chowdhury AN, Mondal R, Brahma A, Biswas MK. Eco-psychiatry and environmental conservation. Study from Sundarban Delta, India. Environ Health Insights 2008;2:61-76.

38.Jeffery GS, Chakrapani U. Eco-psychiatry and Environmental Conservation. Study from Sundarban Delta, India. Working Paper- Research Gate.net. September, 2016.

39.Ozer S, Acculturation, adaptation, and mental health among Ladakhi College Students a mixed methods study of an indigenous population. J Cross Cultl Psychol 2015;46:435-53. 40.Giri DK, Chaudhary S, Govinda M, Banerjee A, Mahto AK, Chakravorty PK. Utilization of psychiatric services by tribal population of Jharkhand through community outreach programme of RINPAS. Eastern J Psychiatry 2007;10:25-9.

41.Nandi DN, Banerjee G, Chowdhury AN, Banerjee T, Boral GC, Sen B. Urbanization and mental morbidity in certain tribal communities in West Bengal. Indian J Psychiatry 1992;34:334-9. [PUBMED] [Full text] 42.Hackett RJ, Sagdeo D, Creed FH. The physical and social associations of common mental disorder in a tribal population in South India.

Soc Psychiatry Psychiatr Epidemiol 2007;42:712-5. 43.Raina SK, Raina S, Chander V, Grover A, Singh S, Bhardwaj A. Development of a cognitive screening instrument for tribal elderly population of Himalayan region in northern India. J Neurosci Rural Pract 2013;4:147-53. [PUBMED] [Full text] 44.Raina SK, Raina S, Chander V, Grover A, Singh S, Bhardwaj A.

Identifying risk for dementia across populations. A study on the prevalence of dementia in tribal elderly population of Himalayan region in Northern India. Ann Indian Acad Neurol 2013;16:640-4. [PUBMED] [Full text] 45.Raina SK, Chander V, Raina S, Kumar D. Feasibility of using everyday abilities scale of India as alternative to mental state examination as a screen in two-phase survey estimating the prevalence of dementia in largely illiterate Indian population.

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Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].

Buy amoxil online without prescription

How to anonymous cite buy amoxil online without prescription this article:Singh OP. Mental health in diverse India. Need for buy amoxil online without prescription advocacy.

Indian J Psychiatry 2021;63:315-6”Unity in diversity” - That is the theme of India which we are quite proud of. We have diversity in terms of geography buy amoxil online without prescription – From the Himalayas to the deserts to the seas. Every region has its own distinct culture and food.

There are so many varieties of dress and language. There is huge difference between the states in terms of development, attitude buy amoxil online without prescription toward women, health infrastructure, child mortality, and other sociodemographic development indexes. There is now ample evidence that sociocultural factors influence mental health.

Compton and Shim[1] have described in their model of gene environment interaction how public policies and social norms act on the distribution of opportunity leading to social inequality, exclusion, poor environment, discrimination, buy amoxil online without prescription and unemployment. This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and early brain insult with low access to health care leads to poor mental health, disease, and morbidity.When we come to the field of mental health, we find huge buy amoxil online without prescription differences between different states of India.

The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the buy amoxil online without prescription more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed northern states had more of childhood onset disorders.

This may be due to lead toxicity, nutritional status, and perinatal issues. Higher rates of buy amoxil online without prescription depression and anxiety were found in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms.

Marriage was found to be a negative prognostic indicator contrary buy amoxil online without prescription to the western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders. The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions.

Apart from culture bound syndromes, the role of cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1–5 lakhs, it was 41,197, and in higher income group, buy amoxil online without prescription it was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these buy amoxil online without prescription require sustained advocacy aimed at promoting rights of mentally ill persons and reducing stigma and discriminations.

It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population. Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and pathways should be to build technical evidence for mapping out the problem, cost-effective interventions, and their efficacy.Advocacy can be done at institutional level, organizational level, buy amoxil online without prescription and individual level.

There has been huge work done in this regard at institution level. Important research work done buy amoxil online without prescription in this regard includes the National Mental Health Survey, National Survey on Extent and Pattern of Substance Use in India, Global Burden of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers.

Similarly, at buy amoxil online without prescription organizational level, the Indian Psychiatric Society (IPS) has filed a case for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from “Mental Hai Kya” to “Judgemental Hai Kya.” In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality. The IPS has also started helplines at different levels and media interactions.

The Indian buy amoxil online without prescription Journal of Psychiatry has also come out with editorials highlighting the need of care of marginalized population such as migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy is economic inequality, our weapon is research highlighting the role of these factors on buy amoxil online without prescription mental health.

References 1.Compton MT, Shim RS. The social determinants buy amoxil online without prescription of mental health. Focus 2015;13:419-25.

2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al. National Mental Health buy amoxil online without prescription Survey of India, 2015-16. Prevalence, Patterns and Outcomes.

Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No. 129.

2016. 3.Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India.

The Global Burden of Disease Study 1990–2017. Lancet Psychiatry 2020;7:148-61. 4.National Crime Records Bureau, 2019.

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Https://ncrb.gov.in. [Last accessed on 2021 Jun 24]. 5.Machado DB, Rasella D, dos Santos DN.

Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015;10:e0124934. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/indianjpsychiatry.indianjpsychiatry_635_21Abstract Sexual health, an essential component of individual's health, is influenced by many complex issues including sexual behavior, attitudes, societal, and cultural factors on the one hand and while on the other hand, biological aspects, genetic predisposition, and associated mental and physical illnesses. Sexual health is a neglected area, even though it influences mortality, morbidity, and disability. Dhat syndrome (DS), the term coined by Dr.

N. N. Wig, has been at the forefront of advancements in understanding and misunderstanding.

The concept of DS is still evolving being treated as a culture-bound syndrome in the past to a syndrome of depression and treated as “a culturally determined idiom of distress.” It is bound with myths, fallacies, prejudices, secrecy, exaggeration, and value-laden judgments. Although it has been reported from many countries, much of the literature has emanated from Asia, that too mainly from India. The research in India has ranged from the study of a few cases in the past to recent national multicentric studies concerning phenomenology and beliefs of patients.

The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature.

It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.Keywords. Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome.

A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr. President, Chairpersons, my respected teachers and seniors, my professional colleagues and friends, ladies and gentlemen:I deem it a proud privilege and pleasure to receive and to deliver DLN Murti Rao Oration Award for 2020.

I am humbled at this great honor and remain grateful to the Indian Psychiatric Society (IPS) in general and the awards committee in particular. I would like to begin my presentation with my homage to Professor DLN Murti Rao, who was a Doyen of Psychiatry.[1] I have a special connection to the name as Dr. Doddaballapura Laxmi Narasimha Murti Rao, apart from a family name, obtained his medical degree from Mysore Medical College, Mysuru, India, the same city where I have served last 33 years in JSS Medical College and JSS Academy of Higher Education and Research.

His name carries the reverence in the corridors of the current National Institute of Mental Health and Neuro Sciences (NIMHANS) at Bangalore which was All India Institute of Mental Health, when he served as Head and the Medical Superintendent. Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS).

Even though Dr. Wig is no more, his legacy of profound contribution to psychiatry and psychiatric education in general and service to the society and Mental Health, in particular, is well documented. His keen observation and study culminated in synthesizing many aspects and developments in DS.I would also like to place on record my humble pranams to my teachers from Christian Medical College, Vellore – Dr.

Abraham Varghese, the first Editor of the Indian Journal of Psychological Medicine and Dr. K. Kuruvilla, Past Editor of Indian Journal of Psychiatry whose legacies I carried forward for both the journals.

I must place on record that my journey in the field of Sexual Medicine was sown by Dr. K. Kuruvilla and subsequent influence of Dr.

Ajit Avasthi from Postgraduate Institute of Medical Education and Research from Chandigarh as my role model in the field. There are many more who have shaped and nurtured my interest in the field of sex and sexuality.The term “Dhat” was taken from the Sanskrit language, which is an important word “Dhatu” and has known several meanings such as “metal,” a “medicinal constituent,” which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for “loss of semen”, and the DS is a well-known “culture-bound syndrome (CBS).”[4] The DS leads to several psychosexual disorders such as physical weakness, tiredness, anxiety, appetite loss, and guilt related to the loss of semen through nocturnal emission, in urine and by masturbation as mentioned in many studies.[4],[5],[6] Conventionally, Charaka Samhita mentions “waste of bodily humors” being linked to the “loss of Dhatus.”[5] Semen has even been mentioned by Aristotle as a “soul substance” and weakness associated with its loss.[6] This has led to a plethora of beliefs about “food-blood-semen” relationship where the loss of semen is considered to reduce vitality, potency, and psychophysiological strength. People have variously attributed DS to excessive masturbation, premarital sex, promiscuity, and nocturnal emissions.

Several past studies have emphasized that CBS leads to “anxiety for loss of semen” is not only prevalent in the Indian subcontinent but also a global phenomenon.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]It is important to note that DS manifestation and the psychosexual features are based on the impact of culture, demographic profiles, and the socioeconomic status of the patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] According to Leff,[21] culture depends upon norms, values, and myths, based on a specific area, and is also shared by the indigenous individuals of that area. Tiwari et al.[22] mentioned in their study that “culture is closely associated with mental disorders through social and psychological activities.” With this background, the paper attempts to highlight the multidimensional construct of DS for a better clinical understanding in routine practice. Dhat Syndrome.

A Separate Entity or a “Cultural Variant” of Depression Even though DS has been studied for years now, a consensus on the definition is yet to be achieved. It has mostly been conceptualized as a multidimensional psychosomatic entity consisting of anxiety, depressive, somatic, and sexual phenomenology. Most importantly, abnormal and erroneous attributions are considered to be responsible for the genesis of DS.

The most important debate is, however, related to the nosological status of DS. Although considered to a CBS unique to India, it has also been increasingly reported in China, Europe, Japan, Malaysia, Russia, and America.[11] The consistency and validity of its diagnosis have been consistently debated, and one of the most vital questions that emerged was. Can there be another way to conceptualize DS?.

There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders. Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue.

Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively. Depression continued to be reported as the most common association of DS in many studies.[25],[26] This “cause-effect” dilemma can never be fully resolved. Whether “loss of semen” and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument.

However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness. Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management. He also mentions that the underlying “emotional distress and cultural contexts” are not unique to DS but can be related to any psychiatric syndrome for that matter.

On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of “mood disorders” can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a “cultural phenotype” of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.

Why Discuss Dhat Syndrome. Implications in Clinical Practice DS might occur independently or associated with multiple comorbidities. It has been a widely recognized clinical condition in various parts of the world, though considered specific to the Indian subcontinent.

The presentation can often be polymorphic with symptom clusters of affective, somatic, behavioral, and cognitive manifestations.[29] Being common in rural areas, the first contacts of the patients are frequently traditional faith healers and less often, the general practitioners. A psychiatric referral occurs much later, if at all. This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder.

Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders. The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being.

Most importantly, the multidimensional presentation of DS can at certain times be a facade overshadowing underlying neurotic disorders (anxiety, depression, somatoform, hypochondriasis, and phobias), obsessive-compulsive spectrum disorders and body dysmorphic disorders, delusional disorders, sexual disorders (premature ejaculation and erectile dysfunction) and infectious disorders (urinary tract s, sexually transmitted diseases), and even stress-related manifestations in otherwise healthy individuals.[4],[14],[15] This significant overlap of symptomatology, increased prevalence, and marked comorbidity make it all the more important for physicians to make sense out of the construct of DS. That can facilitate prompt detection and management of DS in routine clinical practice.In an earlier review study, it was observed that few studies are undertaken to update the research works from published articles as an updated review, systemic review, world literature review, etc., on DS and its management approach.[29],[32],[33],[34],[35] The present paper attempts to compile the evidence till date on DS related to its nosology, critique, manifestations, and management plan. The various empirical studies on DS all over the world will be briefly discussed along with the implications and importance of the syndrome.

The Construct of Dhat Syndrome. Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as “semen loss syndrome” by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with “semen loss anxiety” suffer from a myriad of psychosexual symptoms, which have been attributed to “loss of vital essence through semen” (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale.

The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms. Most commonly associated symptoms were found as per score ≥1. This study reported several parameters such as the “sense of being unhealthy” (99%), worry (99%), feeling “no improvement despite treatment” (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%).

The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness. Overall distress and dysfunction were observed as 64% and 81% in the studied subjects, respectively.A study in Taiwan involved 87 participants from a Urology clinic.

Most of them have sexual neurosis (Shen-K'uei syndrome).[7] More than one-third of the patients belonged to lower social class and symptoms of depression, somatization, anxiety, masturbation, and nocturnal emissions. Other bodily complaints as reported were sleep disturbances, fatigue, dizziness, backache, and weakness. Nearly 80% of them considered that all of their problems were due to masturbatory practices.De Silva and Dissanayake[8] investigated several manifestations on semen loss syndrome in the psychiatric clinic of Colombo General Hospital, Sri Lanka.

Beliefs regarding effects of semen loss and help-seeking sought for DS were explored. 38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years.

Every participant reported excessive loss of semen and was preoccupied with it. The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss.

Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing “Dhat” in urine. They were assessed for a period of 6 months.

More than 80% of them complained of body weakness, aches, and pains. More than 50% of the patients suffered from depression and anxiety. All the participants felt that their symptoms were due to loss of “dhat” in urine, attributed to excessive masturbation, extramarital and premarital sex.

Half of those who faced sexual dysfunctions attributed them to semen loss.Mumford[11] proposed a controversial explanation of DS arguing that it might be a part of other psychiatric disorders, like depression. A total of 1000 literate patients were recruited from a medical outdoor in a public sector hospital in Lahore, Pakistan. About 600 educated patients were included as per Bradford Somatic Inventory (BSI).

Men with DS reported greater symptoms on BSI than those without DS. 60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for “Dhat” items on BSI.

The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness. This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire.

Nearly one-third of the patients were passing “Dhat” multiple times a week. Among them, nearly 60% passed almost a spoonful of “Dhat” each time during a loss. This work on sexual disorders reported that the passage of “Dhat” was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%).

Mostly, the participants experienced passage of Dhat as “night falls” (60.1%) and “while passing stools” (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the “loss of Dhat.” The associated symptoms were depression, hopelessness, feeling low, decreased energy levels, weakness, and lack of pleasure. Erectile problems and premature ejaculation were also present.Rao[17] in his first epidemiological study done in Karnataka, India, showed the prevalence rate of DS in general male population as 12.5%.

It was found that 57.5% were suffering either from comorbid depression or anxiety disorders. The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban).

One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction. The psychosexual symptoms were found among 113 patients who had DS. The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%).

In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice.

The view of participants was that semen is very “precious,” needs preservation, and masturbation is a malpractice. Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders. Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively.

The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments. About 66% of the patients met the DSM-IV diagnostic criteria of depression.

They concluded that depression was a frequent comorbidity in DS patients.In a study by Perme et al.[37] from South India that included 32 DS patients, the control group consisted of 33 people from the same clinic without DS, depression, and anxiety. The researchers followed the guidelines of Bhatia and Malik's for the assessment of primary complaints of semen loss through “nocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.” The assessment was done based on several indices, namely “Somatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.” Several complaints such as somatic complaints, hypochondriacal beliefs, and fatigue were observed to be significantly higher among patients with DS compared to the control group.A study conducted in South Hall (an industrial area in the borough of Middlesex, London) included Indian and Pakistani immigrants. Young men living separately from their wives reported promiscuity, some being infected with gonorrhea and syphilis.

Like other studies, nocturnal emission, weakness, and impotency were the other reported complaints. Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia).

Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India. They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic.

Clinical assessments were done apart from detailed sexual history. The patients were 15–50 years of age, educated up to mid-school and mostly from a rural background. Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age.

There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16–23 years).

The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill. It was assumed in the study that semen loss is considered synonymous to “loss of something precious”, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and “Dhat” in urine (40%) were the common complaints observed.

Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache. More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia.

About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders). Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse.

67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%). Hypochondriasis, sexually transmitted diseases, and depression were the associated comorbidities.

Morrone et al.[50] studied 18 male patients with DS in the Dermatology department who were from Bangladesh and India. The symptoms observed were mainly fatigue and nonspecific somatic symptoms. DS patients manifested several symptoms in psychosocial, religious, somatic, and other domains.

The reasons provided by the patients for semen loss were urinary loss, nocturnal emission, and masturbation. Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas.

In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%–66.7%) were from rural areas, belonged to “conservative families and posed rigid views about sex” (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class. Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss.

They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment.

The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class. Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%).

The subjects were single or unmarried (51.0%) and married (46.7%). About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes.

Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%). About 45.80% of the study subjects were illiterates and very few had completed postgraduation. The subjects were both married and single.

Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone. Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%).

Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16–20 years (34%) followed by 21–25 years (28%), greater than 30 years (26%), 26–30 years (10%), and 11–15 years (2%).

Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively. Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine. In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years.

The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%). Priyadarshi and Verma[43] performed a study in 110 male patients with DS.

The average age of the patients was 23.53 years and it ranged between 15 and 68 years. The most affected age group of patients was of 18–25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years.

Higher percentage of the patients were unmarried (70%). Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively.

Two-third patients belonged to rural areas of residence. Behere and Nataraj[45] found majority of the patients with DS (68%) to be between 16 and 25 years age. About 52% patients were married while 48% were unmarried and from lower socioeconomic strata.

The duration of DS symptoms varied widely. Singh[46] studied patients those who reported with DS, impotence, and premature ejaculation and reported the average age of the affected to be 21.8 years with a younger age of onset. Only a few patients received higher education.

Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single. It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training.

Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%). Most of those who had comorbid DS symptoms received minimal formal education. Management.

A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks. As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal “supplements,” etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help.

The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals. Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone.

Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality. This needs to be tailored to the local terminology and beliefs.

Biofeedback has also been proposed as a treatment modality.[4] Individual stress factors that might have precipitated DS need to be addressed. A detailed outline of assessment, evaluation, and management of DS is beyond the scope of this article and has already been reported in the IPS Clinical Practice Guidelines.[56] The readers are referred to these important guidelines for a comprehensive read on management. Probably, the most important factor is to understand and resolve the sociocultural contexts in the genesis of DS in each individual.

Adequate debunking of the myths related to sexuality and culturally appropriate sexual education is vital both for the prevention and treatment of DS.[56] Adequate treatment of comorbidities such as depression and anxiety often helps in reduction of symptoms, more so when the DS is considered to be a manifestation of the same. Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary.

CBS like DS forms a major area of this nosological controversy. Longitudinal stability of a diagnosis is considered to be an important part of its independent categorization. Sameer et al.[23] followed up DS patients for 6.0 ± 3.5 years and concluded that the “pure” variety of DS is not a stable diagnostic entity.

The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right “place” for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different.

While ICD-10 considers DS under “other nonpsychotic mental disorders” (F48), DSM-V mentions it only in appendix section as “cultural concepts of distress” not assigning the condition any particular number.[12],[58] Fundamental questions have actually been raised about its separate existence altogether,[35] which further puts its diagnostic position in doubt. As discussed in the earlier sections, an alternate hypothesization of DS is a cultural variant of depression, rather than a “true syndrome.”[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural “idiom” of distress in specific geographical regions or a manifestation of other primary psychiatric disorders.[59] Qualitative studies in doctors have led to marked discordance in their opinion about the validity and classificatory area of DS.[60] The upcoming ICD-11 targets to pay more importance to cultural contexts for a valid and reliable classification. However, separating the phenomenological boundaries of diseases might lead to subsetting the cultural and contextual variants in broader rubrics.[61],[62] In that way, ICD-11 might propose alternate models for distinction of CBS like DS at nosological levels.[62] It is evident that various factors include socioeconomics, acceptability, and sustainability influence global classificatory systems, and this might influence the “niche” of DS in the near future.

It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader “narrative” of depression. In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric “construct” which is equally interesting and controversial.

Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality. Beyond the traditional debate about its “separate” existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health. It is also treatable, and hence, the detection, understanding, and awareness become vital to its management.

This oration attempts a “bird's eye” view of this CBS taking into account a holistic perspective of the available evidence so far. The clinical manifestations, diagnostic and epidemiological attributes, management, and nosological controversies are highlighted to provide a comprehensive account of DS and its relevance to mental health. More systematic and mixed methods research are warranted to unravel the enigma of this controversial yet distressing psychiatric disorder.AcknowledgmentI sincerely thank Dr.

Debanjan Banerjee (Senior Resident, Department of Psychiatry, NIMHANS, Bangalore) for his constant selfless support, rich academic discourse, and continued collaboration that helped me condense years of research and ideas into this paper.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.2.3.Srinivasa Murthy R, Wig NN. A man ahead of his time.

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A study on its prevalence in an outpatient setting. Indian J Psychiatry 1997:Suppl 39:53. 42.Bhatia MS, Thakkur KN, Chadda RK, Shome S.

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Dhat syndrome and its social impact. Urol Androl Open J 2015;1:6-11. 44.Nakra BR, Wig NN, Verma VK.

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48.Bhatia MS, Choudhry S, Shome S. Dhat syndrome - Is it a syndrome of Dhat only?. J Ment Health Hum Behav1997;2:17-22.

49.Bhatia MS. An analysis of 60 cases of culture bound syndromes. Indian J Med Sci 1999;53:149-52.

[PUBMED] [Full text] 50.Morrone A, Nosotti L, Tumiati Mc, Cianconi P, Casadei F, Franco G. Dhat Syndrome. An Analysis of 18 Cases.

Paper Presented in 11th Congress of the European Academy of Dermatology &. Venerology. Prague.

Hinjra and jiryan. Two derivatives of Hindu attitudes to sexuality. Br J Med Psychol 1956;29:128-38.

52.Carstairs GM. The Twice Born. Bloomington.

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Psychiatric problems of developing countries. Based on the Morison lecture delivered at the Royal College of Physicians of Edinburgh, on 25 May 1972. Br J Psychiatry 1973;123:271-7.

54.Sathyanarayana Rao TS. Some thoughts on sexualities and research in India. Indian J Psychiatry 2004;46:3-4.

[PUBMED] [Full text] 55.Prakash O, Rao TS. Sexuality research in India. An update.

Indian J Psychiatry 2010;52:S260-3. 56.Avasthi A, Grover S, Rao TS. Clinical practice guidelines for management of sexual dysfunction.

Indian J Psychiatry 2017;59 Suppl 1:S91-115. 57.Kavanoor Sridhar V, Subramanian K, Menon V. Current nosology of Dhat syndrome and state of evidence.

Indian J Health Sex Cult 2018;4:8-14. 58.APA (American Psychological Association). Diagnostic and Statistical Manual of Mental Disorders.

American Psychological Association. 2013. 59.Yasir Arafat SM.

Dhat syndrome. Culture bound, separate entity, or removed. J Behav Health 2017;6:147-50.

60.Prakash S, Sharan P, Sood M. A qualitative study on psychopathology of dhat syndrome in men. Implications for classification of disorders.

Asian J Psychiatr 2018;35:79-88. 61.Lewis-Fernández R, Aggarwal NK. Culture and psychiatric diagnosis.

Adv Psychosom Med 2013;33:15-30. 62.Sharan P, Keeley J. Cultural perspectives related to international classification of diseases-11.

Indian J Soc Psychiatry 2018;34 Suppl S1:1-4. Correspondence Address:T S Sathyanarayana RaoDepartment of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.

How to http://www.modernamenity.com/blog/ cite this buy 250mg amoxil online article:Singh OP. Mental health in diverse India. Need for buy 250mg amoxil online advocacy. Indian J Psychiatry 2021;63:315-6”Unity in diversity” - That is the theme of India which we are quite proud of.

We have diversity in terms of geography – From the Himalayas to buy 250mg amoxil online the deserts to the seas. Every region has its own distinct culture and food. There are so many varieties of dress and language. There is huge difference between the states in terms of development, attitude toward women, health infrastructure, child mortality, and other sociodemographic development indexes buy 250mg amoxil online.

There is now ample evidence that sociocultural factors influence mental health. Compton and Shim[1] have described in their model of gene environment interaction how public policies and social norms buy 250mg amoxil online act on the distribution of opportunity leading to social inequality, exclusion, poor environment, discrimination, and unemployment. This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and early brain insult with low access to health care leads to poor buy 250mg amoxil online mental health, disease, and morbidity.When we come to the field of mental health, we find huge differences between different states of India.

The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed northern states had more of childhood onset disorders buy 250mg amoxil online. This may be due to lead toxicity, nutritional status, and perinatal issues.

Higher rates of depression and buy 250mg amoxil online anxiety were found in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms. Marriage was buy 250mg amoxil online found to be a negative prognostic indicator contrary to the western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders.

The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions. Apart from culture bound syndromes, the role of cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1–5 lakhs, it was 41,197, and in higher income group, it buy 250mg amoxil online was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these require sustained advocacy aimed at promoting rights of mentally ill persons and reducing buy 250mg amoxil online stigma and discriminations.

It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population. Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and pathways should be to build technical evidence for mapping out the problem, cost-effective interventions, and their efficacy.Advocacy can be done buy 250mg amoxil online at institutional level, organizational level, and individual level. There has been huge work done in this regard at institution level.

Important research work done in this regard includes the National Mental Health Survey, National Survey on Extent and Pattern of buy 250mg amoxil online Substance Use in India, Global Burden of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers. Similarly, at organizational buy 250mg amoxil online level, the Indian Psychiatric Society (IPS) has filed a case for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from “Mental Hai Kya” to “Judgemental Hai Kya.” In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality.

The IPS has also started helplines at different levels and media interactions. The Indian Journal of Psychiatry has also come out buy 250mg amoxil online with editorials highlighting the need of care of marginalized population such as migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy is economic inequality, our weapon is research highlighting the role of buy 250mg amoxil online these factors on mental health.

References 1.Compton MT, Shim RS. The social buy 250mg amoxil online determinants of mental health. Focus 2015;13:419-25. 2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al.

National Mental Health Survey buy 250mg amoxil online of India, 2015-16. Prevalence, Patterns and Outcomes. Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No.

129. 2016. 3.Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India.

The Global Burden of Disease Study 1990–2017. Lancet Psychiatry 2020;7:148-61. 4.National Crime Records Bureau, 2019. Accidental Deaths and Suicides in India.

2019. Available from. Https://ncrb.gov.in. [Last accessed on 2021 Jun 24].

5.Machado DB, Rasella D, dos Santos DN. Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015;10:e0124934. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_635_21Abstract Sexual health, an essential component of individual's health, is influenced by many complex issues including sexual behavior, attitudes, societal, and cultural factors on the one hand and while on the other hand, biological aspects, genetic predisposition, and associated mental and physical illnesses.

Sexual health is a neglected area, even though it influences mortality, morbidity, and disability. Dhat syndrome (DS), the term coined by Dr. N. N.

Wig, has been at the forefront of advancements in understanding and misunderstanding. The concept of DS is still evolving being treated as a culture-bound syndrome in the past to a syndrome of depression and treated as “a culturally determined idiom of distress.” It is bound with myths, fallacies, prejudices, secrecy, exaggeration, and value-laden judgments. Although it has been reported from many countries, much of the literature has emanated from Asia, that too mainly from India. The research in India has ranged from the study of a few cases in the past to recent national multicentric studies concerning phenomenology and beliefs of patients.

The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature. It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.Keywords.

Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome. A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr.

President, Chairpersons, my respected teachers and seniors, my professional colleagues and friends, ladies and gentlemen:I deem it a proud privilege and pleasure to receive and to deliver DLN Murti Rao Oration Award for 2020. I am humbled at this great honor and remain grateful to the Indian Psychiatric Society (IPS) in general and the awards committee in particular. I would like to begin my presentation with my homage to Professor DLN Murti Rao, who was a Doyen of Psychiatry.[1] I have a special connection to the name as Dr. Doddaballapura Laxmi Narasimha Murti Rao, apart from a family name, obtained his medical degree from Mysore Medical College, Mysuru, India, the same city where I have served last 33 years in JSS Medical College and JSS Academy of Higher Education and Research.

His name carries the reverence in the corridors of the current National Institute of Mental Health and Neuro Sciences (NIMHANS) at Bangalore which was All India Institute of Mental Health, when he served as Head and the Medical Superintendent. Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS). Even though Dr.

Wig is no more, his legacy of profound contribution to psychiatry and psychiatric education in general and service to the society and Mental Health, in particular, is well documented. His keen observation and study culminated in synthesizing many aspects and developments in DS.I would also like to place on record my humble pranams to my teachers from Christian Medical College, Vellore – Dr. Abraham Varghese, the first Editor of the Indian Journal of Psychological Medicine and Dr. K.

Kuruvilla, Past Editor of Indian Journal of Psychiatry whose legacies I carried forward for both the journals. I must place on record that my journey in the field of Sexual Medicine was sown by Dr. K. Kuruvilla and subsequent influence of Dr.

Ajit Avasthi from Postgraduate Institute of Medical Education and Research from Chandigarh as my role model in the field. There are many more who have shaped and nurtured my interest in the field of sex and sexuality.The term “Dhat” was taken from the Sanskrit language, which is an important word “Dhatu” and has known several meanings such as “metal,” a “medicinal constituent,” which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for “loss of semen”, and the DS is a well-known “culture-bound syndrome (CBS).”[4] The DS leads to several psychosexual disorders such as physical weakness, tiredness, anxiety, appetite loss, and guilt related to the loss of semen through nocturnal emission, in urine and by masturbation as mentioned in many studies.[4],[5],[6] Conventionally, Charaka Samhita mentions “waste of bodily humors” being linked to the “loss of Dhatus.”[5] Semen has even been mentioned by Aristotle as a “soul substance” and weakness associated with its loss.[6] This has led to a plethora of beliefs about “food-blood-semen” relationship where the loss of semen is considered to reduce vitality, potency, and psychophysiological strength. People have variously attributed DS to excessive masturbation, premarital sex, promiscuity, and nocturnal emissions. Several past studies have emphasized that CBS leads to “anxiety for loss of semen” is not only prevalent in the Indian subcontinent but also a global phenomenon.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]It is important to note that DS manifestation and the psychosexual features are based on the impact of culture, demographic profiles, and the socioeconomic status of the patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] According to Leff,[21] culture depends upon norms, values, and myths, based on a specific area, and is also shared by the indigenous individuals of that area.

Tiwari et al.[22] mentioned in their study that “culture is closely associated with mental disorders through social and psychological activities.” With this background, the paper attempts to highlight the multidimensional construct of DS for a better clinical understanding in routine practice. Dhat Syndrome. A Separate Entity or a “Cultural Variant” of Depression Even though DS has been studied for years now, a consensus on the definition is yet to be achieved. It has mostly been conceptualized as a multidimensional psychosomatic entity consisting of anxiety, depressive, somatic, and sexual phenomenology.

Most importantly, abnormal and erroneous attributions are considered to be responsible for the genesis of DS. The most important debate is, however, related to the nosological status of DS. Although considered to a CBS unique to India, it has also been increasingly reported in China, Europe, Japan, Malaysia, Russia, and America.[11] The consistency and validity of its diagnosis have been consistently debated, and one of the most vital questions that emerged was. Can there be another way to conceptualize DS?.

There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders. Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue. Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively.

Depression continued to be reported as the most common association of DS in many studies.[25],[26] This “cause-effect” dilemma can never be fully resolved. Whether “loss of semen” and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument. However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness. Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management.

He also mentions that the underlying “emotional distress and cultural contexts” are not unique to DS but can be related to any psychiatric syndrome for that matter. On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of “mood disorders” can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a “cultural phenotype” of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.

Why Discuss Dhat Syndrome. Implications in Clinical Practice DS might occur independently or associated with multiple comorbidities. It has been a widely recognized clinical condition in various parts of the world, though considered specific to the Indian subcontinent. The presentation can often be polymorphic with symptom clusters of affective, somatic, behavioral, and cognitive manifestations.[29] Being common in rural areas, the first contacts of the patients are frequently traditional faith healers and less often, the general practitioners.

A psychiatric referral occurs much later, if at all. This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder. Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders.

The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being. Most importantly, the multidimensional presentation of DS can at certain times be a facade overshadowing underlying neurotic disorders (anxiety, depression, somatoform, hypochondriasis, and phobias), obsessive-compulsive spectrum disorders and body dysmorphic disorders, delusional disorders, sexual disorders (premature ejaculation and erectile dysfunction) and infectious disorders (urinary tract s, sexually transmitted diseases), and even stress-related manifestations in otherwise healthy individuals.[4],[14],[15] This significant overlap of symptomatology, increased prevalence, and marked comorbidity make it all the more important for physicians to make sense out of the construct of DS. That can facilitate prompt detection and management of DS in routine clinical practice.In an earlier review study, it was observed that few studies are undertaken to update the research works from published articles as an updated review, systemic review, world literature review, etc., on DS and its management approach.[29],[32],[33],[34],[35] The present paper attempts to compile the evidence till date on DS related to its nosology, critique, manifestations, and management plan. The various empirical studies on DS all over the world will be briefly discussed along with the implications and importance of the syndrome.

The Construct of Dhat Syndrome. Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as “semen loss syndrome” by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with “semen loss anxiety” suffer from a myriad of psychosexual symptoms, which have been attributed to “loss of vital essence through semen” (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale. The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms.

Most commonly associated symptoms were found as per score ≥1. This study reported several parameters such as the “sense of being unhealthy” (99%), worry (99%), feeling “no improvement despite treatment” (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%). The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness.

Overall distress and dysfunction were observed as 64% and 81% in the studied subjects, respectively.A study in Taiwan involved 87 participants from a Urology clinic. Most of them have sexual neurosis (Shen-K'uei syndrome).[7] More than one-third of the patients belonged to lower social class and symptoms of depression, somatization, anxiety, masturbation, and nocturnal emissions. Other bodily complaints as reported were sleep disturbances, fatigue, dizziness, backache, and weakness. Nearly 80% of them considered that all of their problems were due to masturbatory practices.De Silva and Dissanayake[8] investigated several manifestations on semen loss syndrome in the psychiatric clinic of Colombo General Hospital, Sri Lanka.

Beliefs regarding effects of semen loss and help-seeking sought for DS were explored. 38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years. Every participant reported excessive loss of semen and was preoccupied with it.

The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss. Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing “Dhat” in urine.

They were assessed for a period of 6 months. More than 80% of them complained of body weakness, aches, and pains. More than 50% of the patients suffered from depression and anxiety. All the participants felt that their symptoms were due to loss of “dhat” in urine, attributed to excessive masturbation, extramarital and premarital sex.

Half of those who faced sexual dysfunctions attributed them to semen loss.Mumford[11] proposed a controversial explanation of DS arguing that it might be a part of other psychiatric disorders, like depression. A total of 1000 literate patients were recruited from a medical outdoor in a public sector hospital in Lahore, Pakistan. About 600 educated patients were included as per Bradford Somatic Inventory (BSI). Men with DS reported greater symptoms on BSI than those without DS.

60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for “Dhat” items on BSI. The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness.

This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire. Nearly one-third of the patients were passing “Dhat” multiple times a week. Among them, nearly 60% passed almost a spoonful of “Dhat” each time during a loss. This work on sexual disorders reported that the passage of “Dhat” was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%).

Mostly, the participants experienced passage of Dhat as “night falls” (60.1%) and “while passing stools” (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the “loss of Dhat.” The associated symptoms were depression, hopelessness, feeling low, decreased energy levels, weakness, and lack of pleasure. Erectile problems and premature ejaculation were also present.Rao[17] in his first epidemiological study done in Karnataka, India, showed the prevalence rate of DS in general male population as 12.5%. It was found that 57.5% were suffering either from comorbid depression or anxiety disorders.

The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban). One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction. The psychosexual symptoms were found among 113 patients who had DS.

The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%). In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice. The view of participants was that semen is very “precious,” needs preservation, and masturbation is a malpractice.

Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders. Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively. The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments.

About 66% of the patients met the DSM-IV diagnostic criteria of depression. They concluded that depression was a frequent comorbidity in DS patients.In a study by Perme et al.[37] from South India that included 32 DS patients, the control group consisted of 33 people from the same clinic without DS, depression, and anxiety. The researchers followed the guidelines of Bhatia and Malik's for the assessment of primary complaints of semen loss through “nocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.” The assessment was done based on several indices, namely “Somatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.” Several complaints such as somatic complaints, hypochondriacal beliefs, and fatigue were observed to be significantly higher among patients with DS compared to the control group.A study conducted in South Hall (an industrial area in the borough of Middlesex, London) included Indian and Pakistani immigrants. Young men living separately from their wives reported promiscuity, some being infected with gonorrhea and syphilis.

Like other studies, nocturnal emission, weakness, and impotency were the other reported complaints. Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia). Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India.

They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic. Clinical assessments were done apart from detailed sexual history. The patients were 15–50 years of age, educated up to mid-school and mostly from a rural background.

Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age. There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16–23 years).

The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill. It was assumed in the study that semen loss is considered synonymous to “loss of something precious”, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and “Dhat” in urine (40%) were the common complaints observed. Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache.

More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia. About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders).

Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse. 67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%). Hypochondriasis, sexually transmitted diseases, and depression were the associated comorbidities.

Morrone et al.[50] studied 18 male patients with DS in the Dermatology department who were from Bangladesh and India. The symptoms observed were mainly fatigue and nonspecific somatic symptoms. DS patients manifested several symptoms in psychosocial, religious, somatic, and other domains. The reasons provided by the patients for semen loss were urinary loss, nocturnal emission, and masturbation.

Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas. In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%–66.7%) were from rural areas, belonged to “conservative families and posed rigid views about sex” (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class.

Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss. They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment.

The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class. Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%). The subjects were single or unmarried (51.0%) and married (46.7%).

About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes. Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%). About 45.80% of the study subjects were illiterates and very few had completed postgraduation.

The subjects were both married and single. Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone. Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%).

Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16–20 years (34%) followed by 21–25 years (28%), greater than 30 years (26%), 26–30 years (10%), and 11–15 years (2%). Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively.

Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine. In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years. The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%).

Priyadarshi and Verma[43] performed a study in 110 male patients with DS. The average age of the patients was 23.53 years and it ranged between 15 and 68 years. The most affected age group of patients was of 18–25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years.

Higher percentage of the patients were unmarried (70%). Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively. Two-third patients belonged to rural areas of residence.

Behere and Nataraj[45] found majority of the patients with DS (68%) to be between 16 and 25 years age. About 52% patients were married while 48% were unmarried and from lower socioeconomic strata. The duration of DS symptoms varied widely. Singh[46] studied patients those who reported with DS, impotence, and premature ejaculation and reported the average age of the affected to be 21.8 years with a younger age of onset.

Only a few patients received higher education. Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single. It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training.

Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%). Most of those who had comorbid DS symptoms received minimal formal education. Management. A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks.

As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal “supplements,” etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help. The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals.

Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone. Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality. This needs to be tailored to the local terminology and beliefs.

Biofeedback has also been proposed as a treatment modality.[4] Individual stress factors that might have precipitated DS need to be addressed. A detailed outline of assessment, evaluation, and management of DS is beyond the scope of this article and has already been reported in the IPS Clinical Practice Guidelines.[56] The readers are referred to these important guidelines for a comprehensive read on management. Probably, the most important factor is to understand and resolve the sociocultural contexts in the genesis of DS in each individual. Adequate debunking of the myths related to sexuality and culturally appropriate sexual education is vital both for the prevention and treatment of DS.[56] Adequate treatment of comorbidities such as depression and anxiety often helps in reduction of symptoms, more so when the DS is considered to be a manifestation of the same.

Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary. CBS like DS forms a major area of this nosological controversy. Longitudinal stability of a diagnosis is considered to be an important part of its independent categorization.

Sameer et al.[23] followed up DS patients for 6.0 ± 3.5 years and concluded that the “pure” variety of DS is not a stable diagnostic entity. The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right “place” for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different.

While ICD-10 considers DS under “other nonpsychotic mental disorders” (F48), DSM-V mentions it only in appendix section as “cultural concepts of distress” not assigning the condition any particular number.[12],[58] Fundamental questions have actually been raised about its separate existence altogether,[35] which further puts its diagnostic position in doubt. As discussed in the earlier sections, an alternate hypothesization of DS is a cultural variant of depression, rather than a “true syndrome.”[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural “idiom” of distress in specific geographical regions or a manifestation of other primary psychiatric disorders.[59] Qualitative studies in doctors have led to marked discordance in their opinion about the validity and classificatory area of DS.[60] The upcoming ICD-11 targets to pay more importance to cultural contexts for a valid and reliable classification. However, separating the phenomenological boundaries of diseases might lead to subsetting the cultural and contextual variants in broader rubrics.[61],[62] In that way, ICD-11 might propose alternate models for distinction of CBS like DS at nosological levels.[62] It is evident that various factors include socioeconomics, acceptability, and sustainability influence global classificatory systems, and this might influence the “niche” of DS in the near future. It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader “narrative” of depression.

In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric “construct” which is equally interesting and controversial. Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality. Beyond the traditional debate about its “separate” existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health.

It is also treatable, and hence, the detection, understanding, and awareness become vital to its management. This oration attempts a “bird's eye” view of this CBS taking into account a holistic perspective of the available evidence so far. The clinical manifestations, diagnostic and epidemiological attributes, management, and nosological controversies are highlighted to provide a comprehensive account of DS and its relevance to mental health. More systematic and mixed methods research are warranted to unravel the enigma of this controversial yet distressing psychiatric disorder.AcknowledgmentI sincerely thank Dr.

Debanjan Banerjee (Senior Resident, Department of Psychiatry, NIMHANS, Bangalore) for his constant selfless support, rich academic discourse, and continued collaboration that helped me condense years of research and ideas into this paper.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.2.3.Srinivasa Murthy R, Wig NN. A man ahead of his time. In.

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None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.