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Credit. The New England Journal of Medicine Share Fast Facts This study clears up how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types. - Click to Tweet The number of mutations in a tumorâs DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors. - Click to Tweet The âmutational burden,â or the number of mutations present in a tumorâs DNA, is a good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, a new study led by Johns Hopkins Kimmel Cancer Center researchers shows. The finding, published in the Dec.

21 New England Journal of Medicine, could be used to guide future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells. As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an . These medicines have had remarkable success in treating some types of cancers that historically have had poor prognoses, such as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma.

The mutational burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow. Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types was unclear. To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data on the mutational burden of thousands of tumor samples from patients with different tumor types.

Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation. The higher a cancer typeâs mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational burden of that cancer. ÂThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive. Itâs one of those things that doesnât sound right when you hear it,â says Hopkins.

ÂBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.â Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors. However, he explains, this cancer type is often caused by a zithromax, which seems to encourage a strong immune response despite the cancerâs lower mutational burden. In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs havenât yet been tried.

Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs. ÂThe end goal is precision medicineâmoving beyond whatâs true for big groups of patients to see whether we can use this information to help any given patient,â he says. Yarchoan receives funding from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation.

Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

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This story can you get zithromax over the counter is the Brand name levitra online first in a two-part series about digital birth control. Read part 2 here.After decades of stagnant birth control research, users are demanding more convenient and safer options â particularly given the potential risks, such as breast cancer, depression and even changes in brain function, associated with hormonal methods.For a small proportion of U.S. Women, fertility awareness methods (FAMs) provide a hormone-free alternative and involve meticulous tracking of oneâs fertile window, which is the number of days within the menstrual cycle in can you get zithromax over the counter which a person can become pregnant.

This can be determined via measurements such as basal (at-rest) body temperature, cervical mucus patterns and the luteinizing hormone (LH) levels in urine. During the fertile window, FAM practitioners commonly rely on withdrawal or barrier methods such as condoms to avoid pregnancy.While they were long considered relatively obscure and can you get zithromax over the counter were commonly associated with religious populations, FAMs now reach a far broader audience via cell phone apps. Over 100 such apps exist, and they have been downloaded more than 200 million times.

More broadly, a whole host of womenâs health apps are advertised to track periods and plan or prevent pregnancy, and often claim to empower users with detailed information on their reproductive health can you get zithromax over the counter. In fact, the slight uptick in the use of FAMs over approximately the past 15 years might have been influenced by dissatisfaction with conventional birth control methods, says Rachel Peragallo Urrutia, an OB-GYN at the University of North Carolina School of Medicine. Urrutia has evaluated the effectiveness of various FAMs to prevent pregnancy (and she receives part of her salary from a health can you get zithromax over the counter care company that promotes these techniques, but she is not involved with any app companies).

ÂI think more people are looking for their own information about their health and wanting to have more say and involvement in decisions around their health," she says. "Theyâre doing their research."FDA-Cleared AppsIn 2018, Natural Cycles became the first mobile medical app cleared by the FDA to be marketed as a can you get zithromax over the counter contraceptive method. It incorporates usersâ basal temperature readings, which users are advised to take every morning, into its algorithm to identify days in which unprotected sex is most likely to result in pregnancy.The Natural Cycles app uses basal body temperature readings to help determine users' fertile windows.

(Credit. Natural Cycles)This controversial precedent arrived amid allegations that the FDA has compromised its standards and leaned into industry lobbying when assessing medical devices. The agency allowed the Clue app, which had previously offered period tracking services, to be advertised as birth control in 2021.

The latter received a slightly different format of clearance. Unlike Natural Cycles, Clueâs contraceptive feature relies purely on statistical analysis of period start dates from users, along with other data from previous studies, to pinpoint days associated with pregnancy risk â without requesting temperature checks. The company claims a distinct advantage over other fertility awareness techniques that require meticulous user labor.

Uncertain EfficacyFAMs can vary widely in effectiveness, depending on the specific technique, and calculations from the digital contraceptive apps place them on the higher end. Natural Cycles raised doubts when a Swedish hospital observed that 37 of the 668 women who sought an abortion between September and December 2017 had used the app for birth control. But the number of pregnancies still aligns with the appâs disclosed efficacy rate.In a U.S.

Study, Natural Cycles reported approximately 98 percent effectiveness at preventing pregnancy when using the app precisely as intended, while typical use (which accounts for mistakes such as having unprotected sex on a fertile day) renders it around 93 percent effective. Clue says itâs around 97 percent effective with perfect use and up to 92 percent effective with typical use. By comparison, typical use of the IUD measures over 99 percent effective, while the pill measures around 91 percent and male condoms around 87 percent.

Unlike Natural Cycles, the Clue app relies entirely on statistical analysis to determine fertile and non-fertile days (Credit. Clue)But some researchers have questioned whether the industry-funded studies that generate these percentages for digital contraception provide a clear enough picture of their efficacy, particularly since theyâre based on observational studies rather than the more rigorous trials associated with FDA-approved birth control methods. Clueâs contraceptive algorithm was originally developed and later evaluated by independent researchers, but the 2019 European Journal of Contraception &.

Reproductive Health Care study was based on merely 718 people compared to the thousands of subjects assessed by Natural Cycles.People looking to avoid pregnancy with the help of technology may also encounter several apps that havenât even been specifically studied or approved for that purpose, Urrutia found.What's more, menstruation tracking apps donât typically publish enough specifics behind their proprietary algorithms for us to truly understand how well they work, or allow outside scientists to plug in data for further analysis. This is indicative of a broader tech industry concern.âIt may be worth pressing on the issue of how not sharing the algorithm might be especially harmful in this case, as compared to other circumstances when proprietary algorithms are not shared,â says Marielle Gross, a bioethicist and OB-GYN at the University of Pittsburgh Medical Center who has researched the monetization of menstrual app data.Natural Cycles told Discover that the company worked closely with the FDA to confirm its efficacy claims, is audited annually to receive the CE safety marking in Europe, and regularly tracks and follows up with unintended pregnancies. But outside of Natural Cycles staff, only regulators can explore the algorithm in detail.

Clue confirmed the same for its algorithm.Ultimately, it isnât clear how often human versus app error can explain accidental pregnancies. Certain mistakes could stem from the method itself, for example, when algorithms mistakenly tell users theyâre clear to have unprotected sex during the fertile window. Natural Cycles does publicize how their algorithm fails around 0.5 percent of the time.

And body temperature can be affected by events like alcohol consumption, illness, and a lack of sleep, the company recognizes, though they say the algorithm can exclude temperature in those situations.Overall, studies seem to indicate that FAM users most commonly experience unintended pregnancies after having sex on days when fertility awareness methods acknowledge the risk, Urrutia adds.Another prevalent concern. Contraceptive apps may not work for people whose cycles deviate from the standard length, Gross says. Factors associated with irregular cycles include stress, polycystic ovary syndrome and ââendometriosis.Clue does warn that it can only be used by certain populations, including women between 18 and 45 years old and those with recent cycles between 20 and 40 days.

But the FDA deemed Natural Cycles as appropriate for people with irregular periods, and the company says that this subset of users may be told to use protection on a higher proportion of days to account for a potential shift in ovulation timing (which is confirmed by temperature data).The Natural Cycle algorithm also incorporates usersâ cycle shifts from abortions, miscarriages and relevant lifestyle factors, a company spokesperson says. ÂWe have studied fertility and cycle effects due to smoking and BMI, but have not seen significant impact and the algorithm thus handles these cases from the get-go."Moving forward, Natural Cycles plans to incorporate readings from the Oura ring, a device originally intended to track sleep and physical activity, that measures heart rate and body temperature. It could provide users with additional non-fertile days, Natural Cycles claims â but this conclusion was based on just 40 subjects.

The FDA cleared the add-on last summer.This piece has been updated after clarifications from the Natural Cycles and Clue teams..

This story is the first in a buy zithromax australia two-part series about digital birth control. Read part 2 here.After decades of stagnant birth control research, users are demanding more convenient and safer options â particularly given the potential risks, such as breast cancer, depression and even changes in brain function, associated with hormonal methods.For a small proportion of U.S. Women, fertility awareness methods (FAMs) provide a hormone-free alternative and involve meticulous tracking of oneâs fertile window, buy zithromax australia which is the number of days within the menstrual cycle in which a person can become pregnant.

This can be determined via measurements such as basal (at-rest) body temperature, cervical mucus patterns and the luteinizing hormone (LH) levels in urine. During the fertile window, buy zithromax australia FAM practitioners commonly rely on withdrawal or barrier methods such as condoms to avoid pregnancy.While they were long considered relatively obscure and were commonly associated with religious populations, FAMs now reach a far broader audience via cell phone apps. Over 100 such apps exist, and they have been downloaded more than 200 million times.

More broadly, a whole host of womenâs health apps buy zithromax australia are advertised to track periods and plan or prevent pregnancy, and often claim to empower users with detailed information on their reproductive health. In fact, the slight uptick in the use of FAMs over approximately the past 15 years might have been influenced by dissatisfaction with conventional birth control methods, says Rachel Peragallo Urrutia, an OB-GYN at the University of North Carolina School of Medicine. Urrutia has evaluated the effectiveness of various FAMs to prevent pregnancy (and she receives part of her salary from a health care company that promotes buy zithromax australia these techniques, but she is not involved with any app companies).

ÂI think more people are looking for their own information about their health and wanting to have more say and involvement in decisions around their health," she says. "Theyâre doing their research."FDA-Cleared AppsIn 2018, Natural buy zithromax australia Cycles became the first mobile medical app cleared by the FDA to be marketed as a contraceptive method. It incorporates usersâ basal temperature readings, which users are advised to take every morning, into its algorithm to identify days in which unprotected sex is most likely to result in pregnancy.The Natural Cycles app uses basal body temperature readings to help determine users' fertile windows.

The FDA cleared the add-on last summer.This piece has been updated after clarifications from the Natural Cycles and Clue teams..

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

dark yellow or brown urine;
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Can zithromax cure uti

ELK CITY can zithromax cure uti see post â One student throws his classmatesâ pencil box on the floor in anger. Another bites her own arm out of frustration. Others run can zithromax cure uti screaming from their classrooms.

Some Elk City Elementary School students are celebrating as summer break approaches. Others are dreading the end of the school year, acting out in fear of what the next three months could bring. School counselor Kim Hamm worries about students who wonât have can zithromax cure uti enough to eat this summer.

And those without air conditioning or running water. She wonders how many will be left alone while their caretakers are working two or three jobs. And who will spend can zithromax cure uti their days anticipating the next attack from an abusive family member.

Hamm has spent most of May helping students ages 4 to 9 identify and cope with their feelings, which can be triggered by instability at home. âThey know that, here, theyâre safe and weâre not going to hurt them,â Hamm said. ÂAnd a lot of our kids, unfortunately, donât go home to that every day.â About 100 miles west of Oklahoma City on can zithromax cure uti Interstate 40, Elk City is home to nearly 12,000 residents whose financial stability ebbs and flows with the volatile oil and gas industry.

The nearby North Fork Correctional Facility brought some families to town to be close to a loved one. And students face rates of poverty, special needs and suicide higher than the state average. Kim Hamm, an Elk can zithromax cure uti City Elementary School counselor, talks to a pre-kindergarten student who is playing with sensory toys purchased with Project AWARE funds in her office.

Hamm said disadvantaged, abused and neglected studentsâ behavior deteriorates toward the end of the school year because theyâre afraid or stressed about spending months away from school, which provides safety when life at home is turbulent. (Courtesy photo) In her six years as a school counselor, Hamm has learned to anticipate these needs, making more time towards the end of the school year to meet with students one-on-one. But she can zithromax cure uti doesnât always have the bandwidth.

School counselorsâ duties range from helping develop individualized learning plans for students with special needs to proctoring the third-grade reading test. They enroll students in classes and ensure they meet state math and science requirements. They provide college and career advice can zithromax cure uti and help them find and apply for scholarships.

They wrangle students during morning drop-off and afternoon pick-up, run school-sponsored food and clothes pantries and teach breathing techniques to those with test anxiety. Low pay and increasing obligations have left Oklahoma with a teacher shortage, which means counselors like Hamm are taking on can zithromax cure uti more work leaving less time for struggling students. Counselors refer the most troubled kids to community mental health counselors.

But they are also in short supply especially in rural areas like Elk City where the ratio of mental healthcare providers to residents is 1 to 150,000. Without adequate local resources, the responsibility of studentsâ mental health care is falling to school counselors who are can zithromax cure uti outnumbered and overwhelmed. A federal program is increasing support for students in six rural school districts in what the state mental health and education departments call âmental health deserts.â But schools are finding it difficult to hire qualified caregivers and buy antibiotics restrictions have halted programs and limited in-person treatment.

Students are seen leaving Elk City Elementary School at the end of the school day. School counselor Kim Hamm said for some students school is a safe place and leaving is not a happy but fearful time of day for students who can zithromax cure uti donât have enough to eat or are abused by family members at home. (Whitney Bryen/Oklahoma Watch) A Response Inspired By Sandy Hook Since 2018, the State Department of Education has received two U.S.

Department of Health and Human Services grants totaling $18 million. Oklahomaâs Project AWARE, short for Advancing Wellness and Resiliency in Education, is in its third year of the five-year grant can zithromax cure uti at Woodward, Elk City and Weatherford Public Schools and its first year at Ada, Atoka and Checotah Public Schools. Subscribe to Jennifer Palmer's Education Watch newsletter Processingâ¦ Success!.

You're on the list. Whoops! can zithromax cure uti. There was an error and we couldn't process your subscription.

Please reload the page and try again. The districts were chosen by the state department for their lack of can zithromax cure uti treatment providers and high-risk student populations. Oklahoma students are some of the most traumatized in the nation, according to several national health rankings including a recent survey conducted by a group based at Johns Hopkins University.

But kids in these rural districts were more likely to have access to firearms, live in poverty, have an incarcerated parent, use drugs, experience depression and die by suicide, according to the stateâs grant application. These students can zithromax cure uti are more susceptible to mental illness. And without treatment, they can face even more dangerous obstacles as they age, often leading to their own violent encounters, substance abuse or incarceration.

Subscribe to our can zithromax cure uti First Watch newsletter Processingâ¦ Success!. You're on the list. Whoops!.

There was can zithromax cure uti an error and we couldn't process your subscription. Please reload the page and try again. In one of the countryâs deadliest school shootings, a 20-year-old killed six adults and 20 students at Sandy Hook Elementary School in 2012.

Since then, the Substance Abuse and Mental Health Services Administration has sent millions to schools nationwide with high-risk students to prevent violence perpetrated can zithromax cure uti by young people. This story was reported in partnership with the Solutions Journalism Network. For more information, go to solutionsjournalism.org.

In their first year of the grant, Atoka, Ada and can zithromax cure uti Checotah schools in Eastern Oklahoma spent most of the year assessing student needs and training staff. At Elk City, Weatherford and Woodward schools in Western Oklahoma, Project AWARE forged ahead despite changes to programs that were derailed by the zithromax. Community events aim to reduce stigma around mental health challenges and treatment and teach parents and students about healthy habits like the importance of sleep and recommendations for social media use.

Elk City paused events in the spring of 2020 while Weatherford took its can zithromax cure uti online and saw a spike in participation. Fifth through 12th grade students at all six districts completed mental health assessments, which helps educators identify students who are distracted, unhappy, scared, lonely or are prone to acting out. Community mental health counselors had started to meet with troubled students in some of the Western Oklahoma schools.

Parents have to agree to therapy but bringing professionals can zithromax cure uti into the schools reduces barriers for families who lack transportation or who feel embarrassed visiting a local treatment facility. Many of these services were paused due to buy antibiotics. Some Project AWARE schools started group therapy sessions led by licensed mental health professionals for students with chronic stress often triggered by traumatic experiences like an absent or abusive parent.

The grant also trained educators at all six districts in a can zithromax cure uti classroom program that teaches conflict resolution and empathy. Liz Henthorn, a kindergarten teacher at Elk City Elementary School, listens as her students rate how theyâre feeling at the end of the day. Henthorn checks in with her students twice a day through a program known as Circles that she says teaches students coping skills and empathy.

(Whitney Bryen/Oklahoma Watch) Just before the bell rang on a Monday afternoon, kindergarteners sat in a circle on a rug at the front can zithromax cure uti of Liz Henthornâs classroom at Elk City Elementary School. One-by-one the students rated how theyâre feeling as they prepared to go home. They describe their feelings as green, yellow or red if theyâre having a difficult day and can zithromax cure uti their peers offer comfort and advice.

One student said he was feeling sad because his dog ran away that morning. Another student was feeling red because she had a bad dream. Other students spoke up saying they could relate or that theyâre sorry that can zithromax cure uti happened.

âWeâre teaching kids to identify their feelings and giving suggestions to cope,â Henthorn said. ÂAnd when we do it as a group the kids are learning about empathy and thinking about ways to help each other and that is just as important.â Liz Henthorn, a kindergarten teacher at Elk City Elementary School, listens as her students rate how theyâre feeling at the end of the day. (Whitney Bryen/Oklahoma can zithromax cure uti Watch) Teachers, counselors and administrators were trained to provide coping skills to students who face universal challenges like disagreements with classmates or stress about what to do after graduation.

But few are qualified to help more critical students, like those with mental illness or who have experienced trauma. Woodward Public Schools reported 82 homeless students during the 2017-18 school year â more than twice the state average. Nearly two-thirds of students at Woodward and Elk City Public Schools qualified for free can zithromax cure uti and reduced lunches, compared to the stateâs average of 50%.

In Elk City, 140 of the districtâs 2,110 students had a parent who was incarcerated. And all three Western Oklahoma districts had higher than average suicide rates. Those districts can zithromax cure uti rely on school counselors to support these students, though most lack the training.

And the grant does not address the ratio of counselors to students, which is far above national recommendations. Districts also planned to increase referrals to community treatment centers facilitated by the grant. Demand for mental health care spiked during the zithromax, further straining the areaâs providers and leaving can zithromax cure uti families with few options.

Weatherford elementary students are seen eating lunch in the schoolâs cafeteria. (Whitney Bryen/Oklahoma Watch) The Complicated Search for Counselors School counselors can listen to students and offer coping techniques, but their ability to help is limited. Licensed counselors can provide therapy and diagnose students with can zithromax cure uti mental illness.

Elk City, Woodward and Weatherford districts hoped to bring more licensed professional counselors into schools by hiring new staff and using Project AWARE funds to pay for training for current school counselors. Each district hired one licensed mental health can zithromax cure uti provider who serves all students. The districts have been unable to hire any new school counselors and no existing counselors have been licensed.

The state requires school counselors to have a masterâs degree in a related field or two years of experience, and pass the stateâs general education, professional teaching and school counseling exams. Training for licensed professional counselors requires an additional 60 graduate-level college can zithromax cure uti hours and 3,000 hours of supervised counseling. Counselors must also pass an exam before being licensed.

Education costs are likely to total $21,000 to $33,000 depending on the school, according to the most recent state averages. And that doesnât include fees can zithromax cure uti for supervision or the licensing exam. The grant will pay tuition costs for school counselors to get their license.

Only two of 16 school counselors in Elk City, Weatherford and Woodward have taken the offer. School counselors said it is still an expensive and lengthy endeavour that results in more work without a boost in pay or can zithromax cure uti a promotion. âI know that it would give me more in depth counseling training, but I think at this time in my life with small children itâs just probably not going to happen,â said Hamm, who has a 10-month-old and a 3-year-old.

ÂIf I was going to make more as a school counselor with it then maybe I would, but Iâm not going to so Iâm just not going to spend a whole lot of time to get that.â For school counselors who do get their license, the job doesnât change much. They often can zithromax cure uti have the same paperwork, testing responsibilities and recess duty. But theyâre also counseling the schoolâs most traumatized kids, a group that is growing following the zithromax.

Oklahoma has 1,841 school counselors and nearly 695,000 students, according to State Department of Education reports. The department does can zithromax cure uti not track how many school counselors have their professional counseling license. The American School Counselor Association recommends a ratio of 1 school counselor to 250 students.

Oklahoma mandates 1 school counselor per 450 middle and high school students. The state does can zithromax cure uti not have a threshold for elementary schools. Not every school has a dedicated counselor.

Some have teams depending on student population, how schools prioritize funding and disperse tasks. The Association also recommends counselors spend at least 80% of their time working directly with can zithromax cure uti or for individual students. Oklahoma Watch interviewed 10 counselors across the state.

Most said they spend the majority of their day doing clerical can zithromax cure uti work. Depending on the time of year, about 20 to 50% of their time is spent with students. Elizabeth Moss, a seventh and eighth grade counselor at Woodward Middle School, said she is one of the fortunate ones because she spends about 50% of her time meeting with students one-on-one thanks to the help of her administration.

Even with the group sessions she leads, Moss said she can zithromax cure uti still hasnât been able to meet the national recommendation. ÂA lot of what I deal with are the results of families who are in crisis, where thereâs addiction, other issues that are related to poverty and the kids show up to school and thereâs a lot of fallout from that,â Moss said. ÂAnd so we have kids who are depressed.

Weâve had kids who are can zithromax cure uti suicidal. Anxieties are really high.â Lora Anderson, a school counselor at Ada Junior High School, talks to students about online enrollment and how to choose classes for next school year. (Courtesy photo) Moss is one of two school counselors taking advantage of Project AWARE funding to get her professional counseling license.

Her principal took over her ACT and pre-ACT testing, scheduling and enrollment duties allowing Moss to spend more time with students in crisis. âI would love to see even more taken off of the shoulders of counselors so that we could take care of our kidsâ needs better,â Moss said. ÂBut I truly feel blessed here that I am not overwhelmed, like so many counselors.â At Ada Junior High School, counselor Lora Anderson spends about 25% of her time working with troubled students.

Many school counselors go into the job to propel studentsâ academic success, not to provide therapy. Anderson does her best to help students but said she isnât trained to help kids with acute needs. ÂThatâs not what I want to do,â Anderson said after returning to her desk from lunch duty.

ÂI do so many different things to help students. If I wanted to be a mental health counselor, I wouldnât work in a school.â Michelle Taylor, President-Elect of the Oklahoma School Counselor Association and counselor at Adair High School, said the job has changed a lot since she started and counselors at smaller schools like hers are often overwhelmed juggling paperwork, test proctoring and counseling students. (Courtesy photo) Michelle Taylor, President-Elect of the Oklahoma School Counselor Association, said the organization doesnât track how many school counselors have their license.

But based on training sheâs attended and led over the years, Taylor said itâs likely that about 1 in 5 school counselors goes on to become licensed. School counselors are serving dual roles whether they want to or not. Like swim instructors at a pool, most school counselors see their role as building stronger swimmers.

But as mental health challenges continue to grow, counselors also have to serve as lifeguards, diving into the deep end to rescue drowning kids. âCounselors in rural schools tend to be treading more water,â Taylor said. ÂSome folks are so overwhelmed with the job they have, they donât have the time or the motivation to seek out additional training.

Itâs just not accessible for folks.â Taylor has been a school counselor for more than 20 years and has her professional counseling license. She currently works with students at Adair High School in northeast Oklahoma. She said the job has changed a lot since she started.

Test requirements are constantly evolving. College admissions and scholarship applications seem to get longer every year. And students want to talk more.

Kids are more willing to open up about their issues, especially since mental health is talked about more openly since the zithromax, Taylor said. And school counselors have to be ready to listen and help. âI think we should be the ones doing this work because we already know the students and they already know us so itâs quicker to get to that trust that can take a long time to develop,â Taylor said.

ÂThatâs when it becomes about priorities and we have to respond to what the students need first and then worry about everything else.â Elk City Middle School students took a mental health screening at the beginning of Lana Grahamâs geography class in March. Graham said since the antibiotics zithromax began, her students seem more anxious and depressed than ever. (Whitney Bryen/Oklahoma Watch) Whitney Bryen is an investigative reporter and visual storyteller at Oklahoma Watch with an emphasis on domestic violence, mental health and nursing homes affected by buy antibiotics.

Contact her at (405) 201-6057 or wbryen@oklahomawatch.org. Follow her on Twitter @SoonerReporter. Support our publicationEvery day we strive to produce journalism that matters â stories that strengthen accountability and transparency, provide value and resonate with readers like you.This work is essential to a better-informed community and a healthy democracy.

But it isnât possible without your support. Donate now.

ELK CITY â One student throws his classmatesâ pencil buy zithromax australia box on the floor in anger. Another bites her own arm out of frustration. Others run screaming from their classrooms buy zithromax australia.

Some Elk City Elementary School students are celebrating as summer break approaches. Others are dreading the end of the school year, acting out in fear of what the next three months could bring. School counselor Kim Hamm worries about students who wonât buy zithromax australia have enough to eat this summer.

And those without air conditioning or running water. She wonders how many will be left alone while their caretakers are working two or three jobs. And who buy zithromax australia will spend their days anticipating the next attack from an abusive family member.

Hamm has spent most of May helping students ages 4 to 9 identify and cope with their feelings, which can be triggered by instability at home. âThey know that, here, theyâre safe and weâre not going to hurt them,â Hamm said. ÂAnd a buy zithromax australia lot of our kids, unfortunately, donât go home to that every day.â About 100 miles west of Oklahoma City on Interstate 40, Elk City is home to nearly 12,000 residents whose financial stability ebbs and flows with the volatile oil and gas industry.

The nearby North Fork Correctional Facility brought some families to town to be close to a loved one. And students face rates of poverty, special needs and suicide higher than the state average. Kim Hamm, an Elk buy zithromax australia City Elementary School counselor, talks to a pre-kindergarten student who is playing with sensory toys purchased with Project AWARE funds in her office.

Hamm said disadvantaged, abused and neglected studentsâ behavior deteriorates toward the end of the school year because theyâre afraid or stressed about spending months away from school, which provides safety when life at home is turbulent. (Courtesy photo) In her six years as a school counselor, Hamm has learned to anticipate these needs, making more time towards the end of the school year to meet with students one-on-one. But she buy zithromax australia doesnât always have the bandwidth.

School counselorsâ duties range from helping develop individualized learning plans for students with special needs to proctoring the third-grade reading test. They enroll students in classes and ensure they meet state math and science requirements. They provide college and career advice and help them buy zithromax australia find and apply for scholarships.

They wrangle students during morning drop-off and afternoon pick-up, run school-sponsored food and clothes pantries and teach breathing techniques to those with test anxiety. Low pay and increasing obligations have left Oklahoma with a teacher shortage, which means counselors like Hamm are taking on buy zithromax australia more work leaving less time for struggling students. Counselors refer the most troubled kids to community mental health counselors.

But they are also in short supply especially in rural areas like Elk City where the ratio of mental healthcare providers to residents is 1 to 150,000. Without adequate local buy zithromax australia resources, the responsibility of studentsâ mental health care is falling to school counselors who are outnumbered and overwhelmed. A federal program is increasing support for students in six rural school districts in what the state mental health and education departments call âmental health deserts.â But schools are finding it difficult to hire qualified caregivers and buy antibiotics restrictions have halted programs and limited in-person treatment.

Students are seen leaving Elk City Elementary School at the end of the school day. School counselor Kim Hamm said for some students school is a safe place and leaving is not a happy but fearful time of day for students who donât have enough to eat or are abused by family members at buy zithromax australia home. (Whitney Bryen/Oklahoma Watch) A Response Inspired By Sandy Hook Since 2018, the State Department of Education has received two U.S.

Department of Health and Human Services grants totaling $18 million. Oklahomaâs Project AWARE, short for Advancing Wellness and Resiliency in Education, is in its buy zithromax australia third year of the five-year grant at Woodward, Elk City and Weatherford Public Schools and its first year at Ada, Atoka and Checotah Public Schools. Subscribe to Jennifer Palmer's Education Watch newsletter Processingâ¦ Success!.

You're on the list. Whoops! buy zithromax australia. There was an error and we couldn't process your subscription.

Please reload the page and try again. The districts were chosen by the state department for their lack of treatment providers and buy zithromax australia high-risk student populations. Oklahoma students are some of the most traumatized in the nation, according to several national health rankings including a recent survey conducted by a group based at Johns Hopkins University.

But kids in these rural districts were more likely to have access to firearms, live in poverty, have an incarcerated parent, use drugs, experience depression and die by suicide, according to the stateâs grant application. These students are more susceptible to mental buy zithromax australia illness. And without treatment, they can face even more dangerous obstacles as they age, often leading to their own violent encounters, substance abuse or incarceration.

Subscribe buy zithromax australia to our First Watch newsletter Processingâ¦ Success!. You're on the list. Whoops!.

There was an error buy zithromax australia and we couldn't process your subscription. Please reload the page and try again. In one of the countryâs deadliest school shootings, a 20-year-old killed six adults and 20 students at Sandy Hook Elementary School in 2012.

Since then, the Substance Abuse and Mental Health Services Administration has sent millions buy zithromax australia to schools nationwide with high-risk students to prevent violence perpetrated by young people. This story was reported in partnership with the Solutions Journalism Network. For more information, go to solutionsjournalism.org.

In their first year of the grant, Atoka, Ada and Checotah schools in Eastern Oklahoma spent buy zithromax australia most of the year assessing student needs and training staff. At Elk City, Weatherford and Woodward schools in Western Oklahoma, Project AWARE forged ahead despite changes to programs that were derailed by the zithromax. Community events aim to reduce stigma around mental health challenges and treatment and teach parents and students about healthy habits like the importance of sleep and recommendations for social media use.

Elk City paused events in the spring of 2020 while Weatherford took its online buy zithromax australia and saw a spike in participation. Fifth through 12th grade students at all six districts completed mental health assessments, which helps educators identify students who are distracted, unhappy, scared, lonely or are prone to acting out. Community mental health counselors had started to meet with troubled students in some of the Western Oklahoma schools.

Parents have to agree to therapy but bringing professionals into buy zithromax australia the schools reduces barriers for families who lack transportation or who feel embarrassed visiting a local treatment facility. Many of these services were paused due to buy antibiotics. Some Project AWARE schools started group therapy sessions led by licensed mental health professionals for students with chronic stress often triggered by traumatic experiences like an absent or abusive parent.

The grant also trained educators at buy zithromax australia all six districts in a classroom program that teaches conflict resolution and empathy. Liz Henthorn, a kindergarten teacher at Elk City Elementary School, listens as her students rate how theyâre feeling at the end of the day. Henthorn checks in with her students twice a day through a program known as Circles that she says teaches students coping skills and empathy.

(Whitney Bryen/Oklahoma Watch) Just before the bell rang on a Monday buy zithromax australia afternoon, kindergarteners sat in a circle on a rug at the front of Liz Henthornâs classroom at Elk City Elementary School. One-by-one the students rated how theyâre feeling as they prepared to go home. They describe their feelings as green, yellow or red if theyâre having a difficult buy zithromax australia day and their peers offer comfort and advice.

One student said he was feeling sad because his dog ran away that morning. Another student was feeling red because she had a bad dream. Other students spoke up saying they could buy zithromax australia relate or that theyâre sorry that happened.

âWeâre teaching kids to identify their feelings and giving suggestions to cope,â Henthorn said. ÂAnd when we do it as a group the kids are learning about empathy and thinking about ways to help each other and that is just as important.â Liz Henthorn, a kindergarten teacher at Elk City Elementary School, listens as her students rate how theyâre feeling at the end of the day. (Whitney Bryen/Oklahoma Watch) Teachers, counselors and buy zithromax australia administrators were trained to provide coping skills to students who face universal challenges like disagreements with classmates or stress about what to do after graduation.

But few are qualified to help more critical students, like those with mental illness or who have experienced trauma. Woodward Public Schools reported 82 homeless students during the 2017-18 school year â more than twice the state average. Nearly two-thirds of students buy zithromax australia at Woodward and Elk City Public Schools qualified for free and reduced lunches, compared to the stateâs average of 50%.

In Elk City, 140 of the districtâs 2,110 students had a parent who was incarcerated. And all three Western Oklahoma districts had higher than average suicide rates. Those districts rely on school counselors buy zithromax australia to support these students, though most lack the training.

Weatherford elementary students are seen eating lunch in the schoolâs cafeteria. (Whitney Bryen/Oklahoma Watch) The Complicated Search for Counselors School counselors can listen to students and offer coping techniques, but their ability to help is limited. Licensed counselors can buy zithromax australia provide therapy and diagnose students with mental illness.

Elk City, Woodward and Weatherford districts hoped to bring more licensed professional counselors into schools by hiring new staff and using Project AWARE funds to pay for training for current school counselors. Each district hired one licensed mental health provider who serves buy zithromax australia all students. The districts have been unable to hire any new school counselors and no existing counselors have been licensed.

The state requires school counselors to have a masterâs degree in a related field or two years of experience, and pass the stateâs general education, professional teaching and school counseling exams. Training for licensed professional counselors requires an additional 60 graduate-level college hours buy zithromax australia and 3,000 hours of supervised counseling. Counselors must also pass an exam before being licensed.

Education costs are likely to total $21,000 to $33,000 depending on the school, according to the most recent state averages. And that doesnât include fees buy zithromax australia for supervision or the licensing exam. The grant will pay tuition costs for school counselors to get their license.

Only two of 16 school counselors in Elk City, Weatherford and Woodward have taken the offer. School counselors said it is still an expensive and lengthy endeavour that results in more work without a boost in buy zithromax australia pay or a promotion. âI know that it would give me more in depth counseling training, but I think at this time in my life with small children itâs just probably not going to happen,â said Hamm, who has a 10-month-old and a 3-year-old.

ÂIf I was going to make more as a school counselor with it then maybe I would, but Iâm not going to so Iâm just not going to spend a whole lot of time to get that.â For school counselors who do get their license, the job doesnât change much. They often have the same paperwork, testing responsibilities and recess buy zithromax australia duty. But theyâre also counseling the schoolâs most traumatized kids, a group that is growing following the zithromax.

Oklahoma has 1,841 school counselors and nearly 695,000 students, according to State Department of Education reports. The department does not track how many school buy zithromax australia counselors have their professional counseling license. The American School Counselor Association recommends a ratio of 1 school counselor to 250 students.

Oklahoma mandates 1 school counselor per 450 middle and high school students. The state does not have a threshold for elementary schools buy zithromax australia. Not every school has a dedicated counselor.

Some have teams depending on student population, how schools prioritize funding and disperse tasks. The Association also recommends counselors spend at least 80% of their time working directly buy zithromax australia with or for individual students. Oklahoma Watch interviewed 10 counselors across the state.

Most said they spend the majority of their day buy zithromax australia doing clerical work. Depending on the time of year, about 20 to 50% of their time is spent with students. Elizabeth Moss, a seventh and eighth grade counselor at Woodward Middle School, said she is one of the fortunate ones because she spends about 50% of her time meeting with students one-on-one thanks to the help of her administration.

Even with buy zithromax australia the group sessions she leads, Moss said she still hasnât been able to meet the national recommendation. ÂA lot of what I deal with are the results of families who are in crisis, where thereâs addiction, other issues that are related to poverty and the kids show up to school and thereâs a lot of fallout from that,â Moss said. ÂAnd so we have kids who are depressed.

Weâve had kids who buy zithromax australia are suicidal. Anxieties are really high.â Lora Anderson, a school counselor at Ada Junior High School, talks to students about online enrollment and how to choose classes for next school year. (Courtesy photo) Moss is one of two school counselors taking advantage of Project AWARE funding to get her professional counseling license.

Her principal took over her ACT and pre-ACT testing, scheduling and enrollment duties allowing Moss to spend more time with students buy zithromax australia in crisis. âI would love to see even more taken off of the shoulders of counselors so that we could take care of our kidsâ needs better,â Moss said. ÂBut I truly feel blessed here that I am not overwhelmed, like so many counselors.â At Ada Junior High School, counselor Lora Anderson spends about 25% of her time working with troubled students.

Many school counselors go into the job to propel studentsâ academic success, not to provide buy zithromax australia therapy. Anderson does her best to help students but said she isnât trained to help kids with acute needs. ÂThatâs not what I want to do,â Anderson said after returning to her desk from lunch duty.

ÂI do so many different things buy zithromax australia to help students. If I wanted to be a mental health counselor, I wouldnât work in a school.â Michelle Taylor, President-Elect of the Oklahoma School Counselor Association and counselor at Adair High School, said the job has changed a lot since she started and counselors at smaller schools like hers are often overwhelmed juggling paperwork, test proctoring and counseling students. (Courtesy photo) Michelle Taylor, President-Elect of the Oklahoma School Counselor Association, said the organization doesnât track how many school counselors have their license.

But based on training sheâs attended and led buy zithromax australia over the years, Taylor said itâs likely that about 1 in 5 school counselors goes on to become licensed. School counselors are serving dual roles whether they want to or not. Like swim instructors at a pool, most school counselors see their role as building stronger buy zithromax australia swimmers.

But as mental health challenges continue to grow, counselors also have to serve as lifeguards, diving into the deep end to rescue drowning kids. âCounselors in rural schools tend to be treading more water,â Taylor said. ÂSome folks are so overwhelmed with the job they have, they donât buy zithromax australia have the time or the motivation to seek out additional training.

Test requirements are constantly evolving. College admissions and scholarship applications seem to get longer every year. And students want to buy zithromax australia talk more.

But it isnât possible without your support. Donate now.

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Centene Corp cheap zithromax online. Will pay a combined $143 million to Ohio and Mississippi to settle allegations that the St. Louis-based insurer overcharged cheap zithromax online states' Medicaid departments for drugs.

The company will also reserve $1.1 billion for future settlements related to its Envolve pharmacy benefit manager, which it has now restructured to serve solely as a third-party administrator to process customer claims. A Centene spokesperson declined to provide information about other investigations currently pending against the payer's pharmacy benefit manager. The settlement will benefit, at least in part, a group cheap zithromax online of plaintiffs represented by the Liston &.

Deas and Cohen &. Milstein law firm, which reportedly is consulting at least four other states about their pharmacy benefit manager programs.Under these agreements, Centene will pay $88 million to Ohio and $55 million to Mississippi. The Ohio Attorney General has dismissed the cheap zithromax online lawsuit against the company.

The settlement does not represent an admission of guilt by Centene. Attorneys General from Ohio and cheap zithromax online Mississippi did not immediately respond to interview requests. "We respect the deep and critically important relationships we have with our state partners," Brent Layton, president of health plans, markets and products at Centene, said in a statement.

"These agreements reflect the significance we place on addressing their concerns and our ongoing commitment to making the delivery of healthcare local, simple and transparent. Importantly, putting these issues behind us allows cheap zithromax online us to continue our relentless focus on delivering high-quality outcomes to our members."The settlement relates to the company's pharmacy benefit operations in 2017 and 2018. Centene said it restructured Envolve's operations in 2019 and on Monday announced it will now no longer operate as a pharmacy benefit manager.

In early March, Ohio Attorney General Dave Yost sued Centene, alleging the St. Louis-based insurer used a "web of subcontractors" to obscure drug costs and overcharge the state's Medicaid program by cheap zithromax online millions of dollars in pharmacy benefits. Centene countered that Yost lacked a "basic understanding" of the state's $26 billion Medicaid program, claiming he wasted taxpayer time and money by accusing the corporation of overcharging for drugs.

The lawsuit came at a critical time for the insurerâOhio recently awarded new contracts for its Medicaid managed-care program, and the state's Medicaid agency deferred its decision about Centene's bid due to the investigation. Ohio will move to cheap zithromax online operate its own pharmacy benefit manager, which it claims will save $240 million in Medicaid drug costs. In April, the Mississippi's attorney general launched an investigation into the insurer's pharmacy benefit management practices for allegedly misleading the state's Medicaid program about drug costs, which resulted in overpayments.

Centene, for its part, called the claims "unfounded," adding that the company is "committed to the highest levels of quality and transparency." The insurer said that Mississippi officials reviewed the pharmacy contracts before they went into effect and that Centene's services saved taxpayers cheap zithromax online millions of dollars compared to market-based drug pricing. The settlement comes as enrollment in Medicaid grows. At the end of Centene's most recent quarter on March 31, the company reported 13.8 million Medicaid members, a more than 2 million enrollee increase from 11.8 million counted during the same time the year before.

The insurer generated $20.1 billion from this cheap zithromax online line up of business, up 16% from 2020. Centene said states are more interested in contracting out their Medicaid program operations. "We continue to have active dialogues with our state partners," the company wrote in its most recent earnings filing with the Securities and Exchange Commission.At the same time as more states partner with third-parties to manage the health of their Medicaid enrollees, more states have begun to question the work of pharmacy benefit managers, which typically work to manage benefits and negotiate drug pricing with pharmaceutical companies and drugstores for government agencies.

Like Centene, many large health plans operate their own PBM as a way to control cheap zithromax online drug costsâUnitedHealthcare, Cigna and CVS all house their own PBMs. CVS owns the Aetna insurer. In May, CVS was hit with a suit from seven insurers, accusing the company of scheming with pharmacy benefit managers to overcharge health plans for generic cheap zithromax online drugs.

This suit represents one of at least six related complaints against CVS. UnitedHealthcare has been hit with at least one suit over its pharmacy benefit manager operations too, with Ohio seeking to recoup at least $16 million in what it says it overpaid the insurer for drugs. Georgia, Arkansas, Kansas and New Mexico have cheap zithromax online all also contracted with Liston &.

Deas and Cohen &. Milstein to investigate their pharmacy benefit managers, according to the Wall Street Journal. A partner at the law firm told cheap zithromax online the newspaper that the number of states working with its practice is "certainly growing." Liston &.

Deas and Cohen &. Milstein did not immediately respond to an interview request..

Centene Corp buy zithromax australia have a peek at this web-site. Will pay a combined $143 million to Ohio and Mississippi to settle allegations that the St. Louis-based insurer overcharged states' Medicaid buy zithromax australia departments for drugs. The company will also reserve $1.1 billion for future settlements related to its Envolve pharmacy benefit manager, which it has now restructured to serve solely as a third-party administrator to process customer claims. A Centene spokesperson declined to provide information about other investigations currently pending against the payer's pharmacy benefit manager.

The settlement buy zithromax australia will benefit, at least in part, a group of plaintiffs represented by the Liston &. Deas and Cohen &. Milstein law firm, which reportedly is consulting at least four other states about their pharmacy benefit manager programs.Under these agreements, Centene will pay $88 million to Ohio and $55 million to Mississippi. The Ohio buy zithromax australia Attorney General has dismissed the lawsuit against the company. The settlement does not represent an admission of guilt by Centene.

Attorneys General from Ohio and Mississippi did buy zithromax australia not immediately respond to interview requests. "We respect the deep and critically important relationships we have with our state partners," Brent Layton, president of health plans, markets and products at Centene, said in a statement. "These agreements reflect the significance we place on addressing their concerns and our ongoing commitment to making the delivery of healthcare local, simple and transparent. Importantly, putting these issues behind us allows us to continue our relentless focus on delivering high-quality buy zithromax australia outcomes to our members."The settlement relates to the company's pharmacy benefit operations in 2017 and 2018. Centene said it restructured Envolve's operations in 2019 and on Monday announced it will now no longer operate as a pharmacy benefit manager.

In early March, Ohio Attorney General Dave Yost sued Centene, alleging the St. Louis-based insurer used a "web buy zithromax australia of subcontractors" to obscure drug costs and overcharge the state's Medicaid program by millions of dollars in pharmacy benefits. Centene countered that Yost lacked a "basic understanding" of the state's $26 billion Medicaid program, claiming he wasted taxpayer time and money by accusing the corporation of overcharging for drugs. The lawsuit came at a critical time for the insurerâOhio recently awarded new contracts for its Medicaid managed-care program, and the state's Medicaid agency deferred its decision about Centene's bid due to the investigation. Ohio will move to operate its own pharmacy benefit manager, which it claims will save $240 million in Medicaid buy zithromax australia drug costs.

In April, the Mississippi's attorney general launched an investigation into the insurer's pharmacy benefit management practices for allegedly misleading the state's Medicaid program about drug costs, which resulted in overpayments. Centene, for its part, called the claims "unfounded," adding that the company is "committed to the highest levels of quality and transparency." The insurer said that Mississippi officials reviewed the pharmacy contracts before they went into effect and that Centene's services saved buy zithromax australia taxpayers millions of dollars compared to market-based drug pricing. The settlement comes as enrollment in Medicaid grows. At the end of Centene's most recent quarter on March 31, the company reported 13.8 million Medicaid members, a more than 2 million enrollee increase from 11.8 million counted during the same time the year before. The insurer generated $20.1 buy zithromax australia billion from this line up of business, up 16% from 2020.

Centene said states are more interested in contracting out their Medicaid program operations. "We continue to have active dialogues with our state partners," the company wrote in its most recent earnings filing with the Securities and Exchange Commission.At the same time as more states partner with third-parties to manage the health of their Medicaid enrollees, more states have begun to question the work of pharmacy benefit managers, which typically work to manage benefits and negotiate drug pricing with pharmaceutical companies and drugstores for government agencies. Like Centene, many large health plans operate their own PBM as a buy zithromax australia way to control drug costsâUnitedHealthcare, Cigna and CVS all house their own PBMs. CVS owns the Aetna insurer. In May, CVS was hit with a suit from seven insurers, accusing the company of buy zithromax australia scheming with pharmacy benefit managers to overcharge health plans for generic drugs.

This suit represents one of at least six related complaints against CVS. UnitedHealthcare has been hit with at least one suit over its pharmacy benefit manager operations too, with Ohio seeking to recoup at least $16 million in what it says it overpaid the insurer for drugs. Georgia, Arkansas, Kansas and New Mexico have buy zithromax australia all also contracted with Liston &. Deas and Cohen &. Milstein to investigate their pharmacy benefit managers, according to the Wall Street Journal.

A partner at buy zithromax australia the law firm told the newspaper that the number of states working with its practice is "certainly growing." Liston &. Deas and Cohen &. Milstein did not immediately respond to an interview request..

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Aug. 29, 2020 -- Chadwick Boseman, the star of the 2018 Marvel Studios megahit Black Panther, died of colon cancer Friday. He was 43. Boseman, who was diagnosed 4 years ago, had kept his condition a secret. He filmed his recent movies ''during and between countless surgeries and chemotherapy," according to a statement issued on his Twitter account.

When the actor was diagnosed in 2016, the cancer was at stage III -- meaning it had already grown through the colon wall -- but then progressed to the more lethal stage IV, meaning it had spread beyond his colon. Messages of condolences and the hashtag #Wakandaforever, referring to the fictional African nation in the Black Panther film, flooded social media Friday evening. Oprah tweeted. "What a gentle gifted SOUL. Showing us all that Greatness in between surgeries and chemo.

The courage, the strength, the Power it takes to do that. This is what Dignity looks like. " Marvel Studios tweeted. "Your legacy will live on forever." Boseman was also known for his role as Jackie Robinson in the movie 42. Coincidentally, Friday was Major League Baseball's Jackie Robinson Day, where every player on every team wears Robinson's number 42 on their jerseys.

Boseman's other starring roles include portraying James Brown in Get on Up and U.S. Supreme Court Justice Thurgood Marshall in Marshall. But his role as King T'Challa in Black Panther, the super hero protagonist, made him an icon and an inspiration. About Colon Cancer Boseman's death reflects a troubling recent trend, says Mark Hanna, MD, a colorectal surgeon at City of Hope, a comprehensive cancer center near Los Angeles. "We have noticed an increasing incidence of colorectal cancer in young adults," says Hanna, who did not treat Boseman.

"I've seen patients as young as their early 20s." About 104,000 cases of colon cancer will be diagnosed this year, according to American Cancer Society estimates, and another 43,000 cases of rectal cancer will be diagnosed. About 12% of those, or 18,000 cases, will be in people under age 50. As the rates have declined in older adults due to screening, rates in young adults have steadily risen. Younger patients are often diagnosed at a later stage than older adults, Hanna says, because patients and even their doctors don't think about the possibility of colon cancer. Because it is considered a cancer affecting older adults, many younger people may brush off the symptoms or delay getting medical attention, Hanna says.

In a survey of 885 colorectal cancer patients conducted by Colorectal Cancer Alliance earlier this year, 75% said they visited two or more doctors before getting their diagnosis, and 11% went to 10 or more before finding out. If found early, colon cancer is curable, Hanna says. About 50% of those with colon cancer will be diagnosed at stage I or II, which is considered localized disease, he says. "The majority have a very good prognosis." The 5-year survival rate is about 90% for both stage I and II. But when it progresses to stage III, the cancer has begun to grow into surrounding tissues and the lymph nodes, Hanna says, and the survival rate for 5 years drops to 75%.

About 25% of patients are diagnosed at stage III, he says. If the diagnosis is made at stage IV, the 5-year survival rate drops to about 10% or 15%, he says. Experts have been trying to figure out why more young adults are getting colon cancer and why some do so poorly. "Traditionally we thought that patients who are older would have a worse outlook," Hanna says, partly because they tend to have other medical conditions too. Some experts say that younger patients might have more ''genetically aggressive disease," Hanna says.

"Our understanding of colorectal cancer is becoming more nuanced, and we know that not all forms are the same." For instance, he says, testing is done for specific genetic mutations that have been tied to colon cancer. "It's not just about finding the mutations, but finding the drug that targets [that form] best." Paying Attention to Red Flags "If you have any of what we call the red flag signs, do not ignore your symptoms no matter what your age is," Hanna says. Those are. In 2018, the American Cancer Society changed its guidelines for screening, recommending those at average risk start at age 45, not 50. The screening can be stool-based testing, such as a fecal occult blood test, or visual, such as a colonoscopy.

Hanna says he orders a colonoscopy if the symptoms suggest colon cancer, regardless of a patient's age. Family history of colorectal cancer is a risk factor, as are being obese or overweight, being sedentary, and eating lots of red meat. Sources Mark Hanna, MD, colorectal surgeon and assistant clinical professor of surgery, City of Hope, Los Angeles. American Cancer Society. "Key Statistics for Colorectal Cancer." Twitter statement.

Chadwick Boseman. American Cancer Society. "Colorectal Cancer Risk Factors." American Cancer Society. '"Colorectal Cancer Rates Rise in Younger Adults." American Society of Clinical Oncology annual meeting, May 29-31, 2020. American Cancer Society "Survival Rates for Colorectal Cancer." American Cancer Society.

"Colorectal Cancer Facts &. Figures. 2017-2019." Â© 2020 WebMD, LLC. All rights reserved.FRIDAY, Aug. 28, 2020 (HealthDay News) -- As many as 20% of Americans don't believe in treatments, a new study finds.

Misinformed treatment beliefs drive opposition to public treatment policies even more than politics, education, religion or other factors, researchers say. The findings are based on a survey of nearly 2,000 U.S. Adults done in 2019, during the largest measles outbreak in 25 years. The researchers, from the Annenberg Public Policy Center (APPC) of the University of Pennsylvania, found that negative misperceptions about vaccinations. reduced the likelihood of supporting mandatory childhood treatments by 70%, reduced the likelihood of opposing religious exemptions by 66%, reduced the likelihood of opposing personal belief exemptions by 79%.

"There are real implications here for a treatment for buy antibiotics," lead author Dominik Stecula said in an APPC news release. He conducted the research while at APPC and is now an assistant professor of political science at Colorado State University. "The negative treatment beliefs we examined aren't limited only to the measles, mumps and rubella [MMR] treatment, but are general attitudes about vaccination." Stecula called for an education campaign by public health professionals and journalists, among others, to preemptively correct misinformation and prepare the public to accept a buy antibiotics treatment. Overall, there was strong support for vaccination policies. 72% strongly or somewhat supported mandatory childhood vaccination, 60% strongly or somewhat opposed religious exemptions, 66% strongly or somewhat opposed treatment exemptions based on personal beliefs.

"On the one hand, these are big majorities. Well above 50% of Americans support mandatory childhood vaccinations and oppose religious and personal belief exemptions to vaccination," said co-author Ozan Kuru, a former APPC researcher, now an assistant professor of communications at the National University of Singapore. "Still, we need a stronger consensus in the public to bolster pro-treatment attitudes and legislation and thus achieve community immunity," he added in the release. A previous study from the 2018-2019 measles outbreak found that people who rely on social media were more likely to be misinformed about treatments. And a more recent one found that people who got information from social media or conservative news outlets at the start of the buy antibiotics zithromax were more likely to be misinformed about how to prevent and hold conspiracy theories about it.

With the antibiotics zithromax still raging, the number of Americans needed to be vaccinated to achieve community-wide immunity is not known, the researchers said. The findings were recently published online in the American Journal of Public Health.By Robert Preidt HealthDay Reporter FRIDAY, Aug. 28, 2020 (HealthDay News) -- Breastfeeding mothers are unlikely to transmit the new antibiotics to their babies via their milk, researchers say. No cases of an infant contracting buy antibiotics from breast milk have been documented, but questions about the potential risk remain. Researchers examined 64 samples of breast milk collected from 18 women across the United States who were infected with the new antibiotics (antibiotics) that causes buy antibiotics.

One sample tested positive for antibiotics RNA, but follow-up tests showed that the zithromax couldn't replicate and therefore, couldn't infect the breastfed infant, according to the study recently published online in the Journal of the American Medical Association. "Detection of viral RNA does not equate to . It has to grow and multiply in order to be infectious and we did not find that in any of our samples," said study author Christina Chambers, a professor of pediatrics at the University of California, San Diego. She is also director of the Mommy's Milk Human Milk Research Biorepository. "Our findings suggest breast milk itself is not likely a source of for the infant," Chambers said in a UCSD news release.

To prevent transmission of the zithromax while breastfeeding, wearing a mask, hand-washing and sterilizing pumping equipment after each use are recommended. "We hope our results and future studies will give women the reassurance needed for them to breastfeed. Human milk provides invaluable benefits to mom and baby," said co-author Dr. Grace Aldrovandi, chief of the Division of Infectious Diseases at UCLA Mattel Children's Hospital in Los Angeles. WebMD News from HealthDay Sources SOURCE.

University of California, San Diego, news release, Aug. 19, 2020 Copyright Â© 2013-2020 HealthDay. All rights reserved.Nursing home staff will have to be tested regularly for buy antibiotics, and facilities that fail to do so will face fines, the Trump administration said Tuesday. Even though they account for less than 1% of the nation's population, long-term care facilities account for 42% of buy antibiotics deaths in the United States, the Associated Press reported. There have been more than 70,000 deaths in U.S.

Nursing homes, according to the buy antibiotics Tracking Project. It's been months since the White House first urged governors to test all nursing home residents and staff, the AP reported. WebMD News from HealthDay Copyright Â© 2013-2020 HealthDay. All rights reserved.August 28, 2020 -- Alcohol-based hand sanitizers that are packaged in containers that look like food items or drinks could cause injury or death if ingested, according to a new warning the FDA issued Thursday. Hand sanitizers are being packaged in beer cans, water bottles, juice bottles, vodka bottles and childrenâs food pouches, the FDA said.

Some sanitizers also contain flavors, such as chocolate or raspberry, which could cause confusion. ÂI am increasingly concerned about hand sanitizer being packaged to appear to be consumable products, such as baby food or beverages,â Stephen Hahn, MD, the FDA commissioner, said in a statement. Accidentally drinking hand sanitizer â even a small amount â is potentially lethal to children. ÂThese products could confuse consumers into accidentally ingesting a potentially deadly product,â he said. ÂItâs dangerous to add scents with food flavors to hand sanitizers which children could think smells like food, eat and get alcohol poisoning.â For example, the FDA received a report about a consumer who purchased a bottle that looked like drinkable water but was actually hand sanitizer.

In another report, a retailer informed the agency about a hand sanitizer product that was marketed in a pouch that looks like a childrenâs snack and had cartoons on it. Meanwhile, the FDA's warning list about dangerous hand sanitizers containing methanol continues to grow as some people are drinking the sanitizers to get an alcohol high. Others have believed a rumor, circulated online, that drinking the highly potent and toxic alcohol can disinfect the body, protecting them from buy antibiotics . Earlier this month, the FDA also issued a warning about hand sanitizers contaminated with 1-propanol. Ingesting 1-propanol can cause central nervous system depression, which can be fatal, the agency says.

Symptoms of 1-propanol exposure can include confusion, decreased consciousness, and slowed pulse and breathing. One brand of sanitizer, Harmonic Nature S de RL de MI of Mexico, are labeled to contain ethanol or isopropyl alcohol but have tested positive for 1-propanol contamination. Poison control centers and state health departments have reported an increasing number of adverse events associated with hand sanitizer ingestion, including heart issues, nervous system problems, hospitalizations and deaths, according to the statement. The FDA encouraged consumers and health care professionals to report issues to the MedWatch Adverse Event Reporting program. The agency is working with manufacturers to recall confusing and dangerous products and is encouraging retailers to remove some products from shelves.

The FDA is also updating its list of hand sanitizer products that consumers should avoid. ÂManufacturers should be vigilant about packaging and marketing their hand sanitizers in food or drink packages in an effort to mitigate any potential inadvertent use by consumers,â Hahn said..

He filmed his recent movies ''during and between countless surgeries and chemotherapy," according to a statement issued on his Twitter account. When the actor was diagnosed in 2016, the cancer was at stage III -- meaning it had already grown through the colon wall -- but then progressed to the more lethal stage IV, meaning it had spread beyond his colon. Messages of condolences and the hashtag #Wakandaforever, referring to the fictional African nation in the Black Panther film, flooded social media Friday evening. Oprah tweeted.

"What a gentle gifted SOUL. Showing us all that Greatness in between surgeries and chemo. The courage, the strength, the Power it takes to do that. This is what Dignity looks like.

" Marvel Studios tweeted. "Your legacy will live on forever." Boseman was also known for his role as Jackie Robinson in the movie 42. Coincidentally, Friday was Major League Baseball's Jackie Robinson Day, where every player on every team wears Robinson's number 42 on their jerseys. Boseman's other starring roles include portraying James Brown in Get on Up and U.S.

Supreme Court Justice Thurgood Marshall in Marshall. But his role as King T'Challa in Black Panther, the super hero protagonist, made him an icon and an inspiration. About Colon Cancer Boseman's death reflects a troubling recent trend, says Mark Hanna, MD, a colorectal surgeon at City of Hope, a comprehensive cancer center near Los Angeles. "We have noticed an increasing incidence of colorectal cancer in young adults," says Hanna, who did not treat Boseman.

Because it is considered a cancer affecting older adults, many younger people may brush off the symptoms or delay getting medical attention, Hanna says. In a survey of 885 colorectal cancer patients conducted by Colorectal Cancer Alliance earlier this year, 75% said they visited two or more doctors before getting their diagnosis, and 11% went to 10 or more before finding out. If found early, colon cancer is curable, Hanna says. About 50% of those with colon cancer will be diagnosed at stage I or II, which is considered localized disease, he says.

"The majority have a very good prognosis." The 5-year survival rate is about 90% for both stage I and II. But when it progresses to stage III, the cancer has begun to grow into surrounding tissues and the lymph nodes, Hanna says, and the survival rate for 5 years drops to 75%. About 25% of patients are diagnosed at stage III, he says. If the diagnosis is made at stage IV, the 5-year survival rate drops to about 10% or 15%, he says.

Experts have been trying to figure out why more young adults are getting colon cancer and why some do so poorly. "Traditionally we thought that patients who are older would have a worse outlook," Hanna says, partly because they tend to have other medical conditions too. Some experts say that younger patients might have more ''genetically aggressive disease," Hanna says. "Our understanding of colorectal cancer is becoming more nuanced, and we know that not all forms are the same." For instance, he says, testing is done for specific genetic mutations that have been tied to colon cancer.

"It's not just about finding the mutations, but finding the drug that targets [that form] best." Paying Attention to Red Flags "If you have any of what we call the red flag signs, do not ignore your symptoms no matter what your age is," Hanna says. Those are. In 2018, the American Cancer Society changed its guidelines for screening, recommending those at average risk start at age 45, not 50. The screening can be stool-based testing, such as a fecal occult blood test, or visual, such as a colonoscopy.

"Key Statistics for Colorectal Cancer." Twitter statement. Chadwick Boseman. American Cancer Society. "Colorectal Cancer Risk Factors." American Cancer Society.

'"Colorectal Cancer Rates Rise in Younger Adults." American Society of Clinical Oncology annual meeting, May 29-31, 2020. American Cancer Society "Survival Rates for Colorectal Cancer." American Cancer Society. "Colorectal Cancer Facts &. Figures.

2017-2019." Â© 2020 WebMD, LLC. All rights reserved.FRIDAY, Aug. 28, 2020 (HealthDay News) -- As many as 20% of Americans don't believe in treatments, a new study finds. Misinformed treatment beliefs drive opposition to public treatment policies even more than politics, education, religion or other factors, researchers say.

The findings are based on a survey of nearly 2,000 U.S. Adults done in 2019, during the largest measles outbreak in 25 years. The researchers, from the Annenberg Public Policy Center (APPC) of the University of Pennsylvania, found that negative misperceptions about vaccinations. reduced the likelihood of supporting mandatory childhood treatments by 70%, reduced the likelihood of opposing religious exemptions by 66%, reduced the likelihood of opposing personal belief exemptions by 79%.

72% strongly or somewhat supported mandatory childhood vaccination, 60% strongly or somewhat opposed religious exemptions, 66% strongly or somewhat opposed treatment exemptions based on personal beliefs. "On the one hand, these are big majorities. Well above 50% of Americans support mandatory childhood vaccinations and oppose religious and personal belief exemptions to vaccination," said co-author Ozan Kuru, a former APPC researcher, now an assistant professor of communications at the National University of Singapore. "Still, we need a stronger consensus in the public to bolster pro-treatment attitudes and legislation and thus achieve community immunity," he added in the release.

A previous study from the 2018-2019 measles outbreak found that people who rely on social media were more likely to be misinformed about treatments. And a more recent one found that people who got information from social media or conservative news outlets at the start of the buy antibiotics zithromax were more likely to be misinformed about how to prevent and hold conspiracy theories about it. With the antibiotics zithromax still raging, the number of Americans needed to be vaccinated to achieve community-wide immunity is not known, the researchers said. The findings were recently published online in the American Journal of Public Health.By Robert Preidt HealthDay Reporter FRIDAY, Aug.

28, 2020 (HealthDay News) -- Breastfeeding mothers are unlikely to transmit the new antibiotics to their babies via their milk, researchers say. No cases of an infant contracting buy antibiotics from breast milk have been documented, but questions about the potential risk remain. Researchers examined 64 samples of breast milk collected from 18 women across the United States who were infected with the new antibiotics (antibiotics) that causes buy antibiotics. One sample tested positive for antibiotics RNA, but follow-up tests showed that the zithromax couldn't replicate and therefore, couldn't infect the breastfed infant, according to the study recently published online in the Journal of the American Medical Association.

"Detection of viral RNA does not equate to . It has to grow and multiply in order to be infectious and we did not find that in any of our samples," said study author Christina Chambers, a professor of pediatrics at the University of California, San Diego. She is also director of the Mommy's Milk Human Milk Research Biorepository. "Our findings suggest breast milk itself is not likely a source of for the infant," Chambers said in a UCSD news release.

WebMD News from HealthDay Sources SOURCE. University of California, San Diego, news release, Aug. 19, 2020 Copyright Â© 2013-2020 HealthDay. All rights reserved.Nursing home staff will have to be tested regularly for buy antibiotics, and facilities that fail to do so will face fines, the Trump administration said Tuesday.

Even though they account for less than 1% of the nation's population, long-term care facilities account for 42% of buy antibiotics deaths in the United States, the Associated Press reported. There have been more than 70,000 deaths in U.S. Nursing homes, according to the buy antibiotics Tracking Project. It's been months since the White House first urged governors to test all nursing home residents and staff, the AP reported.

WebMD News from HealthDay Copyright Â© 2013-2020 HealthDay. All rights reserved.August 28, 2020 -- Alcohol-based hand sanitizers that are packaged in containers that look like food items or drinks could cause injury or death if ingested, according to a new warning the FDA issued Thursday. Hand sanitizers are being packaged in beer cans, water bottles, juice bottles, vodka bottles and childrenâs food pouches, the FDA said. Some sanitizers also contain flavors, such as chocolate or raspberry, which could cause confusion.

ÂI am increasingly concerned about hand sanitizer being packaged to appear to be consumable products, such as baby food or beverages,â Stephen Hahn, MD, the FDA commissioner, said in a statement. Accidentally drinking hand sanitizer â even a small amount â is potentially lethal to children. ÂThese products could confuse consumers into accidentally ingesting a potentially deadly product,â he said. ÂItâs dangerous to add scents with food flavors to hand sanitizers which children could think smells like food, eat and get alcohol poisoning.â For example, the FDA received a report about a consumer who purchased a bottle that looked like drinkable water but was actually hand sanitizer.

Ingesting 1-propanol can cause central nervous system depression, which can be fatal, the agency says. Symptoms of 1-propanol exposure can include confusion, decreased consciousness, and slowed pulse and breathing. One brand of sanitizer, Harmonic Nature S de RL de MI of Mexico, are labeled to contain ethanol or isopropyl alcohol but have tested positive for 1-propanol contamination. Poison control centers and state health departments have reported an increasing number of adverse events associated with hand sanitizer ingestion, including heart issues, nervous system problems, hospitalizations and deaths, according to the statement.

The FDA encouraged consumers and health care professionals to report issues to the MedWatch Adverse Event Reporting program. The agency is working with manufacturers to recall confusing and dangerous products and is encouraging retailers to remove some products from shelves. The FDA is also updating its list of hand sanitizer products that consumers should avoid. ÂManufacturers should be vigilant about packaging and marketing their hand sanitizers in food or drink packages in an effort to mitigate any potential inadvertent use by consumers,â Hahn said..

Is zithromax in the penicillin family

How to is zithromax in the penicillin family cite this article:Singh OP. Mental health in diverse India. Need for is zithromax in the penicillin family advocacy.

Indian J Psychiatry 2021;63:315-6âUnity in diversityâ - That is the theme of India which we are quite proud of. We have diversity in terms of geography â From the Himalayas is zithromax in the penicillin family 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 toward women, health infrastructure, is zithromax in the penicillin family 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, is zithromax in the penicillin family discrimination, and unemployment. This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and is zithromax in the penicillin family 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 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 is zithromax in the penicillin family northern states had more of childhood onset disorders.

This may be due to lead toxicity, nutritional status, and perinatal issues. Higher rates of depression is zithromax in the penicillin family 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 to the western norms.[3]Cultural influences on is zithromax in the penicillin family 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 is zithromax in the penicillin family 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 1â5 lakhs, it was 41,197, and in higher income group, 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 require sustained advocacy aimed at promoting rights of mentally ill is zithromax in the penicillin family 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, is zithromax in the penicillin family and their efficacy.Advocacy can be done 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 is zithromax in the penicillin family 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 organizational level, the Indian Psychiatric Society is zithromax in the penicillin family (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 âMental Hai Kyaâ to âJudgemental Hai Kya.â 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 with editorials highlighting the need of care of marginalized population such as migrant laborers and is zithromax in the penicillin family 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 is zithromax in the penicillin family highlighting the role of these factors on mental health.

References 1.Compton MT, Shim RS. The social determinants is zithromax in the penicillin family 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 is zithromax in the penicillin family Health 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 1990â2017. 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 âa culturally determined idiom of distress.â 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 â 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.

Several past studies have emphasized that CBS leads to âanxiety for loss of semenâ 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 âculture is closely associated with mental disorders through social and psychological activities.â 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 âCultural Variantâ 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?.

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 âcause-effectâ dilemma can never be fully resolved. Whether âloss of semenâ 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 âemotional distress and cultural contextsâ 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 âmood disordersâ 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 âcultural phenotypeâ 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.

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 âsemen loss syndromeâ 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 âsemen loss anxietyâ suffer from a myriad of psychosexual symptoms, which have been attributed to âloss of vital essence through semenâ (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 â¥1. This study reported several parameters such as the âsense of being unhealthyâ (99%), worry (99%), feeling âno improvement despite treatmentâ (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 âDhatâ 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 âdhatâ 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 âDhatâ 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 âDhatâ multiple times a week. Among them, nearly 60% passed almost a spoonful of âDhatâ each time during a loss. This work on sexual disorders reported that the passage of âDhatâ 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 ânight fallsâ (60.1%) and âwhile passing stoolsâ (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the âloss of Dhat.â 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 âprecious,â 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 ânocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.â The assessment was done based on several indices, namely âSomatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.â 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 15â50 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 (16â23 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 âloss of something preciousâ, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and âDhatâ 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%â66.7%) were from rural areas, belonged to âconservative families and posed rigid views about sexâ (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 16â20 years (34%) followed by 21â25 years (28%), greater than 30 years (26%), 26â30 years (10%), and 11â15 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 18â25 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.

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 âsupplements,â 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.

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 Â± 3.5 years and concluded that the âpureâ 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 âplaceâ 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 âother nonpsychotic mental disordersâ (F48), DSM-V mentions it only in appendix section as âcultural concepts of distressâ 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 âtrue syndrome.â[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural âidiomâ 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 ânicheâ of DS in the near future.

It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader ânarrativeâ 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 âconstructâ 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 âseparateâ 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 âbird's eyeâ 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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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 buy zithromax australia cite this index article:Singh OP. Mental health in diverse India. Need for buy zithromax australia advocacy. Indian J Psychiatry 2021;63:315-6âUnity in diversityâ - That is the theme of India which we are quite proud of.

We have diversity in terms of geography buy zithromax australia â 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 toward women, health infrastructure, child buy zithromax australia 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 buy zithromax australia 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 mental health, disease, and morbidity.When we come to the field of mental health, we find buy zithromax australia 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 buy zithromax australia 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 zithromax australia 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 to the western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent buy zithromax australia. 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, buy zithromax australia suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1â5 lakhs, it was 41,197, and in higher income group, 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 require sustained advocacy aimed at promoting rights of mentally ill persons and reducing stigma and discriminations buy zithromax australia.

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 zithromax australia 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 Substance Use in India, Global Burden of Diseases in Indian States, and Trajectory buy zithromax australia 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 level, the Indian Psychiatric Society (IPS) has buy zithromax australia 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 âMental Hai Kyaâ to âJudgemental Hai Kya.â 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 with editorials highlighting the need of care of marginalized buy zithromax australia 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 buy zithromax australia economic inequality, our weapon is research highlighting the role of these factors on mental health.

References 1.Compton MT, Shim RS. The social buy zithromax australia 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 buy zithromax australia Health 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 1990â2017. 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 âa culturally determined idiom of distress.â 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.

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.

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 â 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 âDhatâ was taken from the Sanskrit language, which is an important word âDhatuâ and has known several meanings such as âmetal,â a âmedicinal constituent,â which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for âloss of semenâ, and the DS is a well-known âculture-bound syndrome (CBS).â[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 âwaste of bodily humorsâ being linked to the âloss of Dhatus.â[5] Semen has even been mentioned by Aristotle as a âsoul substanceâ and weakness associated with its loss.[6] This has led to a plethora of beliefs about âfood-blood-semenâ 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 âanxiety for loss of semenâ 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 âculture is closely associated with mental disorders through social and psychological activities.â 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 âCultural Variantâ 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 âcause-effectâ dilemma can never be fully resolved. Whether âloss of semenâ 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 âemotional distress and cultural contextsâ 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 âmood disordersâ 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 âcultural phenotypeâ 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.

Most commonly associated symptoms were found as per score â¥1. This study reported several parameters such as the âsense of being unhealthyâ (99%), worry (99%), feeling âno improvement despite treatmentâ (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.

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 âDhatâ 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 âdhatâ in urine, attributed to excessive masturbation, extramarital and premarital sex.

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

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.

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 ânocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.â The assessment was done based on several indices, namely âSomatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.â 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.

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 15â50 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 (16â23 years).

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.

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%â66.7%) were from rural areas, belonged to âconservative families and posed rigid views about sexâ (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.

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%).

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 18â25 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.

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 âsupplements,â 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 Â± 3.5 years and concluded that the âpureâ 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 âplaceâ 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.

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 âconstructâ 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 âseparateâ 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 âbird's eyeâ 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.

Sathyanarayana Rao TS, Tandon A, editors. Psychiatry in India. Training and Training Centres. 2nd ed.

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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.