Price of propecia in canada
When weâre stressed out, our bodyâs internal chemistry useful content changes price of propecia in canada. Cortisol, the primary stress hormone alongside adrenaline and norepinephrine, surges. As a price of propecia in canada result, blood sugar levels increase and more of that glucose is allocated to the brain.Thatâs good â the chain reaction helps our bodies in the so-called âfight-or-flightâ response, which has a deep evolutionary history and dwells within us even today. When potential predators were around, our ancient ancestors needed that extra boost to figure out whether to take them on or run away.
Nowadays, the same biochemical responses spring into action to help us react quickly when weâre under pressure.Our bodies, however, no longer only do this when weâre seriously threatened. The same processes are triggered when weâre late for work or arguing price of propecia in canada with family members. And after dealing with a propecia for over a year, many more Americans are becoming acquainted with prolonged psychological stress, according to the American Psychological Association's latest Stress in America poll. Often times, our response to this stress can be more harmful than helpful.
ÂWe know that the immune system is capable of looking at price of propecia in canada these proteins and reacting,â says Willem van Eden, an immunologist at Utrecht University in the Netherlands. Protracted exposure to higher levels of stress hormones comes along with myriad side effects within the immune system.Largely speaking, stress can be divided into two camps. The psychological and the physical, also known as physicochemical stress. While psychological stress is caused by worrying about something price of propecia in canada (whether itâs a predator or a looming deadline), physical stress comes from environmental factors such as air pollution, poor nutrition or exhaustion.Chronic psychological stress has been linked to a subdued immune system.
But if the immune system becomes compromised and is no longer capable of dealing with physical stresses, this can promote the onset of disease.Scientists first noticed a link between stress and the strength of immune systems during animal experiments in the early 1980s. The experiments quickly progressed to humans when researchers began observing medical students. They found that studentsâ immunity dropped around exam time with depleted levels of T-cells, some of the immune systemâs most important weapons in the fight against price of propecia in canada .Additional studies showed that chronic stress interferes with the molecular signals that immune cells use to communicate with each other. More recently, Scott Mueller, a professor at the University of Melbourne in Australia, demonstrated that stress can even stop immune cells from moving, physically blocking them from thwarting s and cancers.In a 2021 mouse-based study, Mueller and his colleagues used a special microscope â able to observe biological processes within living organisms â to create real-time images of a chemical messenger protein called noradrenaline.
The protein is found in higher concentrations under stressful conditions and obstructs the movement of various white blood cells that are important in the immune response. This âexplains at least in part the widely observed relationship between stress and impaired immunity,â Mueller concludes in the study.Another study, published in Frontiers in Immunology in 2018, demonstrated the impact of stress price of propecia in canada on the immune system by inducing stress and cancerous tumor growth in mice â some of whom were additionally given an antidepressant. The results showed a marked difference. The mice treated with antidepressants had significantly reduced cancer progression compared to those who werenât.While itâs possible that the antidepressants themselves possess cancer-fighting mechanisms, the researchers concluded that the inhibition of psychological distress (thanks to the antidepressant) is likely what restored antitumor immunity.Cancer isnât the only disease that seems to progress more rapidly under stressed environments.
Research has shown that chronic stress also increases a personâs price of propecia in canada risk of heart disease, weight gain, digestive issues, headaches, muscle pain and, of course, mental health problems such as anxiety and depression.In short, our immune systems are at their best when weâre not beset with high levels of cortisol pumping through our veins.This article contains affiliate links to products. We may receive a commission for purchases made through these links.CBD has become one of the most popular wellness products on the planet, and for good reason. The chemical compounds that comprise CBD oil have a wide array of benefits, from sleep support to pain relief to calming properties that help with stress and anxiety, and more. Itâs no wonder that more and more people are turning to CBD oil as price of propecia in canada a part of their daily health regimen.
But what exactly is CBD, and why does it interact the way it does with the human body?. Before we explore the world of cannabis and cannabinoids, such as CBD and THC, letâs take a look at some of the best CBD oils for sale in the UK. The Best CBD Oils UK When shopping for CBD oils, price of propecia in canada the key is to look for quality. There are a lot of unscrupulous CBD companies out there looking to make a quick pound by selling CBD products with poor-quality CBD oil.
Here are some things to look for when shopping for CBD oil. Organic CBD CBD companies canât legally advertise their products in the UK as being organic, but that doesnât mean price of propecia in canada itâs not important. The hemp plant, from which CBD oil is derived, is whatâs known as a bioaccumulator, meaning that it pretty much sucks everything up from its surrounding soil that it can. This is great for soaking in nutrients, but if there are pesticides or other chemicals in the soil, those will be pulled into the cannabis hemp plant as well, and end up in your CBD oil product.
Thatâs why itâs vital to find a CBD company price of propecia in canada that uses naturally grown, organic hemp. CBD Extraction Methods Originally, CBD oil was extracted from the hemp plant by means of steam distillation. This was clean, but inefficient. Then, manufacturers began to price of propecia in canada use various chemical solvents to derive their CBD oil.
This was efficient, but not necessarily clean, as some of those solvents left a chemical residue behind in the oil. CO2 extraction provides the best price of propecia in canada of both worlds. Itâs efficient, pulling all of the cannabinoids, terpenes and flavonoids from the cannabis hemp plant, and itâs clean, leaving no chemical residue behind. The need for purity doesnât end at the cannabis fields.
Insist on price of propecia in canada CBD oil extracted with clean CO2. Third-Party Laboratory Testing Thereâs only one way to know if your CBD oil was organically grown and cleanly extracted with CO2, and thatâs by being able to see a lab report, produced by an independent third-party laboratory. Every legitimate CBD brand will make one of these reports readily available for each of its CBD products. This report will tell you whether youâre getting the potency of CBD youâve been promised, by giving you the exact amount of CBD and other price of propecia in canada cannabinoids in your product.
It will also tell you if there are any chemical contaminants in your CBD product. If you donât see third-party lab reports on a CBD companyâs website, find another CBD company!. Natural Ingredients Many CBD products, including CBD oil drops, contain ingredients other price of propecia in canada than cannabidiol oil. For instance, many CBD oil tinctures will contain a second carrier oil to help the body to better absorb the CBD.
But there are a vast variety of botanicals and other ingredients that are used in CBD products, as well. Make sure to check the ingredients on the label to ensure that price of propecia in canada theyâre all natural. Unnecessary fillers or unhealthy chemicals can sink a CBD product just as easily as a bad CBD oil. Based on the four criteria above â organic cultivation, CO2 extraction, third-party lab testing, and natural ingredients â the CBD oil drops from CBDfx hit the mark every time.
This shouldnât come price of propecia in canada as a surprise. CBDfx has been doing this since 2014, and is one of the most respected brands in the business. They use only organically sourced CBD oil, extracted by clean CO2, and provide the independent, third-party lab reports to back it up. They also use natural ingredients, including flavourings and colours, on all price of propecia in canada of their CBD products.
CBDfx sells two quality CBD oil tinctures in the UK. CBDfx CBD Oil Hemp Tincture Itâs pretty much impossible to find a cleaner ingredient profile on a CBD oil product. The only two ingredients in CBDfxâs CBD Oil Hemp Tincture are broad spectrum CBD oil and all-natural, coconut-derived medium-chain triglyceride oil to price of propecia in canada help with absorption. And thatâs it.
If youâre looking for a pure CBD experience with no flashy add-ons, these are the perfect CBD oil drops. Pure, potent, and price of propecia in canada reasonably priced!. CBDfx CBD + CBG Oil Wellness Tincture Mother Nature provides CBD oil with a special feature called the Entourage Effect. This is the phenomenon by which cannabinoids, terpenes and flavonoids work harder together than they would if taken individually.
Broad spectrum price of propecia in canada CBD provides a rich Entourage Effect experience on its own. But with their CBD + CBG Oil Wellness Tincture, CBDfx gives Mother Nature herself a little boost, by blending CBD and the âMother of All Cannabinoids,â CBG, in an ideal 2:1 ratio, which helps your CBD to work as hard as it possibly can. But they donât stop there. These oil drops also contain curcumin and coenzyme Q10, commonly used in homeopathic remedies, coconut-derived MCT oil, and a special blend of terpenes for added price of propecia in canada wellness benefits.
All of these ingredients combine to make a great daily wellness supplement, ideal for morning health regimens. Now that you have a sense of what to look for in a CBD oil â as well as two fantastic oils to get you started â letâs dig a little deeper into what CBD is, how CBD oil works, and what are some of the benefits of CBD oil. CBD Oil price of propecia in canada Benefits. An Intro to CBD and Cannabis CBD is short for cannabidiol, and itâs one of over a hundred different compounds found in the cannabis plant, called cannabinoids.
Other cannabinoids include THC, CBG, CBN, CBG, and CBC. Cannabinoids, like CBD, are created by structures on the surface of the cannabis plant price of propecia in canada called trichomes. Trichomes also produce terpenes and flavonoids. All of these compounds are produced to protect the cannabis plant from the elements, as well animals that pose a price of propecia in canada threat.
Some of these compounds also attract pollinators, which helps the cannabis plant to thrive and replenish. CBD and Its Effects on the Endocannabinoid System Your body produces its own cannabinoids. These are called price of propecia in canada endocannabinoids, and theyâre part of the endocannabinoid system. The ECS is a cell-signaling system that helps systems and organs throughout the body to maintain homeostasis, or balance.
CBD and other cannabinoids mimic endocannabinoids, when introduced into the body. Interacting with price of propecia in canada receptors in the central and peripheral nervous systems, among others, they send signals to help regulate such crucial functions as memory, mood, appetite, motor control, sleep, pain, stress, and much more. It is the potential benefits of this interaction with the endocannabinoid system that make CBD such an intriguing wellness supplement. The Benefits of CBD Oil Because hemp was historically lumped in with its high-THC sibling, marijuana, by the Home Office, research on its wellness benefits didnât begin in earnest until recent decades.
And even now, not enough price of propecia in canada research has been done for the government in the UK to allow CBD to be used for medical purposes. In fact, CBD brands are not legally allowed to make any medical claims at all regarding its medicinal use. However, that doesnât mean that research isnât being done. And it certainly doesnât sweep aside, literally, thousands of years of use for a variety of purposes price of propecia in canada.
Here are some of the areas where people have experienced the benefits of CBD or hemp oil. CBD Oil for Pain and Inflammation We mentioned that CBD interacts with the bodyâs endocannabinoid system, triggering support for the central and peripheral nervous systems. The peripheral nervous system helps price of propecia in canada the body to manage pain and inflammation. Recent studies have shown that CBD has a wealth of potential in helping to ease aches and pains, and to fight inflammation.
This is why youâll not only see products like CBD oil tinctures used for skin or muscle and joint issues, but youâll also see CBD creams and balms used as well. CBD Oil for Sleep One of the most desirable qualities of CBD is its calming properties price of propecia in canada. It relaxes the nerves and calms the mind and body. This makes CBD an ideal supplement for sleep.
CBD oil price of propecia in canada before bed can help prepare the body for rest and allow you to sleep more soundly through the night. CBD Oil for Stress and Anxiety Those same calming properties we mentioned above can also help to settle the nerves and ease stress. As long-term stressors can lead to anxiety, it can be incredibly beneficial to head them off at the pass with calming CBD oil. CBD Oil for General Wellness It really bears repeating just price of propecia in canada how promising the potential benefits are regarding CBDâs interaction with the endocannabinoid system.
This system has such a wide reach in regulating many of the bodyâs most important functions. By helping to keep the ECS working consistently, CBD oil has the potential to make a huge difference in your overall wellness. This is price of propecia in canada why, for many, CBD oil is a must for their daily health regimen. Can CBD Oil Benefit Your Health?.
For thousands of years, people have used cannabis for a variety of health benefits. CBD oil has been a popular natural product used for issues price of propecia in canada ranging from pain and stress to sleep and more. Can CBD oil benefit you?. Thereâs only one way to find out, and thatâs to experience it for yourself!.
No matter how improbable some myths and legends may seem, many of them are price of propecia in canada rooted in reality. Instances of civilization-destroying floods appearing in many religious narratives across the globe, for example, have led historians to hypothesize that these events may have been inspired by an actual rise in sea levels following the Last Glacial Maximum.Similarly, folkloric creatures like vampires and werewolves are believed to have originated not from the minds of storytellers, but all-too-real diseases and medical conditions which, in times when humanityâs scientific knowledge was not nearly as advanced as it is today, sparked the imaginations of our ancestors, resulting in the legends of monsters we still know and fear. The Vampire price of propecia in canada Hunts Todayâs view of vampires is based heavily on Dracula, the character from Bram Stokerâs 1897 novel of the same name. However, the true origins of these blood-sucking creatures actually goes back further than the publication of the iconic text.
The concept first received widespread attention from western European scholars in 1718, when Austria gained control of Serbia.As they moved into the newly acquired region, Austrian administrators noted local Serbian communities would mark suspicious individuals as âvampires.â Similar to the witch hunts in colonial America, these people often wound up being condemned to death, after which their corpses would be exhumed for traces of dark magic. In his book Vampires, price of propecia in canada Burial and Death, Paul Barber argues that the concept of vampires arose out of an inability to explain the varying speeds at which human bodies can decompose. Nowadays, we can understand these variations are due to a variety of factors including temperature and soil composition. In the Middle Ages and for centuries thereafter, witchcraft filled this gaping hole in our communal knowledge.
Look, for instance, at the curious price of propecia in canada case of Rhode Island resident Mercy Brown. After dying of tuberculosis in the late 1800s, Brownâs body was placed in an above-ground vault. When, at the end of a severe winter, her remains had yet to decompose, she was declared a vampire and held responsible for the mysterious illness (you guessed it â tuberculosis) that afflicted her surviving family members. Vampirism and Blood Disorders Vampires have a number of distinct characteristics, each of which has been linked to price of propecia in canada a particular real-life illness.
According to folklore, vampires are nocturnal creatures whose supernatural powers are severely weakened when they are exposed to the sun â an attribute which, historians suspect, may have been inspired by medical conditions that cause photosensitivity. One of these conditions is lupus, an autoimmune disease where white blood cells attack the bodyâs own organs and tissues. According to WebMD, about two-thirds of lupus patients are sensitive to uaviolet rays, with their symptoms worsening whenever they are exposed to the sun or, in extreme cases, even artificial light price of propecia in canada. Lupus isnât the only cause of photosensitivity, however.
Experts also point to porphyria as a possible origin for the vampire mythos. According to research, sufferers of porphyria â a group of blood disorders defined by unnatural buildups in the natural chemicals that price of propecia in canada produce hemoglobin â either manifest âdelayed, blisteringâ or âimmediate, painfulâ photosensitivity. Itâs easy to see how, in the past, people who were afflicted with porphyria could have been falsely suspected of vampirism. In order to avoid irritating their condition, patients would try to avoid sunlight as much as possible.
Until recently, drawing blood â a practice that reduces both price of propecia in canada the bodyâs iron and porphyrins levels â was a common method for treating the condition.Read More. Real-Life Vampires Exist, and Researchers are Studying ThemWerewolfery. Disease or Delusion?. Just as iconic a monster as the vampire is the werewolf, a creature from European folklore that denotes a human being who â by some curse or affliction â temporarily transforms into an animalistic, bloodthirsty man-wolf at the sight of price of propecia in canada a full moon.
The term is derived from âwerwulf,â an Old English term combining the words for âmanâ and âwolf.âToday, werewolves are monsters of the imagination. In the past, they were regarded as real and actively hunted by superstitious communities. German serial killer Peter Stumpp, who met his death in 1589, was accused of being price of propecia in canada a werewolf. Werewolf trials continued well into the 18th century, with the last known trials taking place in southern Austria.Though the concept of the modern werewolf has its roots in northern Europe, descriptions of people with wolf-like qualities date back to antiquity.
The Greek physician Galen, who lived from 129 to 216 CE, described a patient with the appearance and appetite of a wolf. The term âclinical lycanthropy,â the delusion that one is able to turn price of propecia in canada into an animal, was born from this description. Unlike vampirism, which was almost always âdiagnosedâ through accusation by someone else, oneâs status as a werewolf was often asserted by the afflicted themselves. In the late sixteenth century, the English politician Reginald Scot argued against the accepted beliefs of the day.
The way he saw it, lycanthropy was not price of propecia in canada a disease of the body but of the mind â a delusion.Transfer through BitesIn recent times, historians have looked for medical conditions that could explain the birth of the werewolf myth. In 1963, a medical professional by the name of Lee Illis traced the origins of werewolves back to the same source as vampirism. In his article, On Porphyria and the Aetiology of Werewolves, Illis too settled on the aforementioned family of blood disorders. Considering werewolves and vampires share many characteristics, this should not come as much of a price of propecia in canada surprise.
After all, both monsters are active at night and driven by a lust for blood. In his article, Illis outlined congenital porphyria, which manifests in the form of photosensitivity, reddish teeth and psychosis, as the most convincing price of propecia in canada medical explanation for this mythological phenomenon. Illisâ argument did not go unchallenged. In his 1979 book The Werewolf Delusion, cultural sociologist Ian Woodward argued the physical symptoms of congenital porphyria are too subtle to account for the visual characteristics of werewolves, which in virtually every mythos resemble real wolves more than they do a regular person.Instead, Woodward points to a far more alarming medical condition.
Rabies. The disease, which is almost always contracted from animal bites, represents a bridge between the human and natural world. On top of that, the diseaseâs symptoms â excess saliva, muscle spasms and transfer through bites â strongly resemble descriptions from werewolf legends.From Myth to MedicineVampires and werewolves arenât the only creatures from myth that may have come into existence thanks to misunderstanding real-world diseases and medical conditions. The concept of the zombie â an inhuman undead that can transfer its deadly affliction through physical contact â may have been based on lepers, who for most of history were exiled to isolated locations, lest they infect their neighbors.The relationship between myth and medicine should not be taken lightly.
For much of history, superstition severely hindered the development of modern science. Rather than mythologizing mysterious illnesses and demonizing those who are afflicted by them, medical institutions strive to inform and educate both their patients and the communities in which they live. The more we come to understand how a particular disease works and where it comes from, the better we can avoid the creation of yet another monster.If youâre waking up with aches and pains in your back and neck each morning, it may mean that it is time to look for a new mattress. Finding a mattress that is supportive, that will keep your spine in alignment, and that will offer pressure point relief may help to alleviate the amount of pain you experience.
However, with all the mattress options on the market, it can be overwhelming trying to choose the one that will offer the pressure and pain relief youâre looking for. First, weâll share some tips below to help you shop for the right mattress to match your sleep position, body weight, and pain type. Then, weâll provide an overview of our picks for the best mattresses for back and neck pain. So, whether youâre shopping for the best mattress for lower back pain, upper back pain, neck pain, or sciatic nerve pain, keep reading.
Is My Mattress Responsible for My Back and Neck Pain?. Possibly!. Sleeping on a mattress that doesnât offer the proper support and contouring for your body and sleep position can definitely contribute to back and neck pain. One main cause of back and neck pain is the misalignment of the spine.
Many mattresses that arenât supportive enough based on your sleep position (or that have started to sag over the years), donât keep the spine in alignment. When this occurs, it places undue stress on the body, which can lead to back or neck pain. Of course, there are many causes for back and neck pain. Mattresses are just one possible cause.
If you notice that the level of pain youâre experiencing is greatest in the morning, then your mattress is more likely to be the culprit. However, even if your old mattress isnât necessarily the cause, switching to a new mattress could still help minimize the pain youâre experiencing. You can always schedule an appointment with your physician to assess the cause of your pain. Types of Back and Neck Pain There are different types of back and neck pain.
The type of pain youâre experiencing and its location can play a big role in deciding which mattress is best for you. Back pain is classified as either acute or chronic. Acute back pain typically occurs as the result of an injury to the ligaments or muscles in the back. It often feels like a very sharp pain and may be caused from lifting something that is too heavy, falling, or twisting the body.
Acute back pain often subsides with time or proper treatment. Chronic back pain, on the other hand, lasts for a longer period of time and often does not resolve itself even with treatments. Chronic pain often feels like more of a dull pain, though individuals may also experience sharp pain. The cause for chronic back pain is not always clear, though in some cases individuals may be able to trace their pain back to an older injury.
The area of the back that is affected by the pain is used to categorize types of back pain. These categories include. Lower back pain Mid back pain Upper back pain Neck pain Sleep Position and Body Weight Before choosing a new mattress to help alleviate your back and neck pain, it is essential to consider your sleeping position. The best mattress for a side sleeper may feel quite different from the best mattress for a back sleeper.
This disparity is because each sleep position creates different pressure points. The location of the pressure points can help determine how supportive or cushioning a mattress should be. Side sleepers. Generally speaking, side sleepers prefer a softer mattress than those who sleep in other positions.
This is because the mattress needs to contour to their shoulders and hips and let them sink in a bit to keep the spin aligned. However, if the mattress is too soft, the hips and shoulders will sink in beneath the spine, which can result in misalignment and more pain. Many side sleepers tend to prefer a medium or medium-firm mattress. Back Sleepers.
The pressure points for a back sleeper are found in the lumbar areas along the lower back. Mattresses that are too soft will cause a back sleeperâs lower back and hips to sink into the mattress, resulting in a misaligned spine and increased pain. Because of this fact, most back sleepers are most comfortable on a medium-firm to firm mattress that will give their hips the support they need to keep the spine aligned. Stomach sleepers.
A stomach sleeperâs pressure points are found around their neck and lumbar region. To keep their spine aligned, stomach sleepers tend to need a firm mattress. If the mattress is too soft, then the lower body will sink in more deeply than the upper body, resulting in a misaligned spine and stress on the lower backâs muscles and ligaments. Combination sleepers.
Individuals that rotate between two or three of the different sleep positions over night need to look for a mattress with a balanced firmness that can support the lower back region while they are sleeping on their back or stomach while also being contouring enough to cradle the body when they are sleeping on their side. In addition to your preferred sleep position, your body weight can also impact the ideal firmness level of a mattress. Because of their increased body weight, heavier individuals will sink down into a mattress more than lighter individuals sleeping in the same position. If you weigh over 230 pounds, you may find that a firmer mattress will be more supportive for you to ensure your spine stays in alignment.
On the flip side, if your body weight is less than 130 pounds, you may find that a softer mattress is best for you. The Best Mattresses for Back and Neck Pain Ready to choose a new mattress that will provide the relief youâre seeking for your back or neck pain?. Keep the information we shared about sleep position above in mind as you read through our recommendations. GhostBed Flex Luxury Hybrid Mattress The GhostBed Flex is one of the top choices when youâre looking for the best mattress for lower back pain.
This is product is a hybrid mattress that features individually wrapped coils to offer sufficient support and keep individuals from sinking too deeply into their mattress. Along with the coils, it also offers layers of gel memory foam and GhostBedâs exclusive Ghost Bounce layer that work together to cradle the body, keep the spine in alignment, and provide pressure point pain relief. The GhostBed Flex is rated between a 6 and 7 on the firmness scale, making it a good option for side and back sleepers trying to alleviate back pain. This firmness rating also makes it a balanced option for partners with different firmness preferences.
Some other notable features of the 13-inch GhostBed Flex include the cool-to-the-touch plush cover with cool burst airflow technology fiber woven into the top layer and the Spirited Edge support reinforced coils that make it easier to sit on the edge of the bed. GhostBed mattresses ship for free and include a 25-year warranty and a 101-night sleep trial. Puffy Lux Hybrid Mattress The Puffy Lux Hybrid Mattress is also an excellent selection for those dealing with back pain. This mattress offers 6-layers designed to help it contour to each body and alleviate back pain and discomfort.
The Contour-Adapt coils work alongside the layers of foam, specifically the 1.5-inch Plush Dual Cloud foam layer, to provide support and pressure relief while minimizing the strain placed on the spine. In addition to its pain-relieving properties, there are a number of other benefits offered by the Puffy Lux Mattress. These features include the hypoallergenic cover, the Cooling Cloud foam layer for breathable and comfortable sleep, and the mattressâs compatibility with any type of base. If you purchase a mattress from Puffy, youâll enjoy a 101-night sleep trial to test out the mattress and make sure it is right for you.
Puffy also includes free shipping and an impressive lifetime warranty with all of their mattresses. PlushBeds Botanical Bliss Organic Latex Mattress We think youâll also like the PlushBeds Botanical Bliss Organic Latex Mattress if youâre looking to find relief from back and neck pain. Unlike the mattresses above, this option is not a hybrid mattress. Rather, it is constructed from certified organic latex foam.
One of the reasons that the Botanical Bliss is a top contender for the best mattress for lower back pain is because latex is known for its abilities to cradle the body. This flexibility can help alleviate pressure points and back pain and allow you to enjoy a more restful sleep. In fact, many chiropractors and orthopedic specialists recommend this mattress to patients suffering from back or neck pain. The mattress is available in 9-, 10-, and 12-inch thicknesses with either a medium or medium-firm feel.
Each thickness features layers of OEKO-TEX certified natural talalay latex and GOLS (Global Organic Latex Standard) certified Arpico organic latex. The 9-inch mattress has a 2-inch layer of talalay latex and a 6-inch Arpico organic latex core, the 10-inch mattress has a 3-inch layer of talalay latex and a 6-inch Arpico organic latex core, and the 12-inch mattress has a 2-inch layer of talalay latex, a 3-inch layer of Arpico organic latex, and a 6-inch Arpico organic latex core. In addition to the latex layers, this mattress also features a GOTS (Global Organic Textile Standard) certified organic cotton cover. It also has a GOTS certified organic wool that acts as a natural flame retardant.
The Botanical Bliss Mattress includes free shipping, a 100-night trial, and a 25-year warranty. DreamCloud Luxury Hybrid Mattress If you wake up with back and neck pain, the DreamCloud Luxury Hybrid Mattress may be able to help. This mattress uses a combination of individually-wrapped coils and memory foam to offer relief from pain and to allow individuals to rest more comfortably. The DreamCloud Mattress features a 5-layer design starting with a soft and cozy quilted foam and cashmere cover.
Beneath the cover is the Pressure-Relief Comfort layer. This gel memory foam layer contours to the body to lessen pressure points and keep the spine in alignment for reduced back and neck pain. The next layer, known as the Sink-In-Just Right layer, is designed to provide the right amount of contouring to an individualâs body to keep them comfortable without sinking in so much that it puts stress on their spine. The pocketed coils follow next to allow the mattress to be supportive and adaptive to position changes.
Finally, the base layer gives the mattress stability and helps to ensure all the layers above it work well with one another. The DreamCloud Luxury Hybrid Mattress has a firmness rating of 6.5 out of 10, a good balance for most individuals looking to alleviate back or neck pain. Individuals who tend to get warm when they sleep will also appreciate how the gel memory foam and coils work together to disperse heat and allow air flow for a cool and comfortable nightâs sleep. Each DreamCloud Mattress includes free shipping and a 365-night sleep trial.
DreamCloud also offers a lifetime warranty to protect your purchase. The company also includes pillows, a sheet set, and a mattress protector with each mattress. What to Look for When Shopping for the Best Mattress for Back and Neck Pain Keep the considerations outlined below in mind as you shop for the best mattresses for lower back pain, upper back pain, or neck pain. Using these to guide your search can help ensure that youâll be happy with the mattress you select and that it will actually deliver the pain relief youâre seeking.
Mattress Type There are many different types of mattresses on the market. These options include memory foam, latex, hybrid, innerspring, and air mattresses. Hybrid mattresses are often seen as an optimal pick for individuals with back pain. They deliver the contouring properties of memory foam and latex mattresses to provide pressure point relief, along with the support of an innerspring mattress to help keep the spine in alignment.
Individuals with back pain who sleep on their side may find that a memory foam mattress is a good pick for them. These mattresses can provide excellent contouring and pressure relief to keep the shoulders and hips comfortable and the spine in alignment for side sleepers. Sleeping Position and Firmness Level As we shared above, your sleep position plays an important role when determining your ideal firmness level. Generally speaking, side sleepers will be most comfortable on a medium to medium firm mattress.
Back sleepers will find optimal support from a medium-firm to firm mattress. And stomach sleepers will be most comfortable on a firmer mattress. Budget Keep your budget in mind as well. There can be quite a range of prices between different mattress companies and even models from the same manufacturer.
You should be able to find a mattress that will provide the contouring and support needed to alleviate back and neck pain that matches your budget. Of course, if youâre looking to splurge, youâll be able to find a mattress that comes with more bells and whistles too, such as adjustable air chambers, sleep tracking capabilities, or certified organic materials. Sleep Trials and Warranties Finally, compare the warranty and sleep trial offered by each mattress manufacturer. Choosing a mattress that includes a long warranty (the industry standard is about 10 years) and that comes with an extended sleep trial can help you feel more confident about your decision.
Fortunately, most online mattress companies offer a multi-night sleep trial, typically ranging from a few months up to a year. This trial period will let you see how comfortable the mattress actually feels when you sleep in it and if it helps alleviate your pain. Frequently Asked Questions What mattress type is best for back and neck pain?. In most cases, a hybrid mattress will be best for those dealing with back or neck pain.
Hybrid mattresses have coils that offer excellent support, while also featuring foam or latex layers for contouring and pressure point relief. How firm of a mattress do I need for back pain?. There is no âcorrectâ answer for this question as individual preferences, sleep positions, and body weight can impact the ideal firmness level. In general, side sleepers will require a softer mattress, while back or stomach sleepers will need a firmer mattress.
Can an old mattress cause back and neck pain?. Yes, if your mattress does not offer proper support and pressure point relief, it can cause the spine to become misaligned. This situation can result in neck or back pain. What is the best position to sleep if you have back pain?.
There are a few different positions you can try sleeping in to alleviate back pain. One is to sleep on your side with a pillow between your legs and your legs pulled up slightly towards your upper body. Another idea is to try sleeping on your back with a pillow under your knees. You can also try sleeping on your stomach with a pillow beneath your lower abdomen and pelvis.
Sleep with a low pillow or no pillow at all to avoid placing too much strain on your back in this position. What is the best way to sleep for neck pain?. If youâve been searching for âsleep wrong neck pain,â you know how your sleeping position can impact your neck. Tips for how to sleep with neck pain include sleeping on your side or on your back.
Use a flat pillow under your head and a rounded pillow under your neck to support its curve if you sleep on your back. Feather pillows can also be a good choice for alleviating neck pain. They will conform to the neck to reduce pain. You can also consider choosing a cervical memory foam pillow that is designed to conform to the neck.
When shopping for a pillow for neck pain, do not buy any that are too stiff or too high, since they will keep the neck at an awkward position and may result in pain the following morning. What is the best way to sleep with shoulder pain?. Looking for how to sleep with shoulder pain?. Try one of these tips.
Sleep on your back with a pillow between your thighs. Place one pillow on top of another pillow, slightly staggered, to provide more support for your neck and shoulders. How can you sleep comfortably with sciatic nerve pain?. Sciatic nerve pain can make it difficult to sleep comfortably.
If youâve been looking for a solution for how to sleep with sciatic nerve pain or how to sleep with lower back pain and sciatica, here are a few things you can try. Sleep on your side with a pillow between your legs. If you prefer sleeping on your back, elevate your legs by placing pillows under your legs until your knees and back are comfortable.This story originally appeared in our November/December 2021 issue as "Cardiac Crisis." Click here to subscribe to read more stories like this one.The symptoms that brought Louis to the Keck Hospital of University of Southern California seemed less than concerning at first glance. The 41-year-old said heâd been feeling weak and short of breath for the past three weeks, and his feet were swollen.But vague symptoms can sometimes conceal life-threatening dangers.
Soon after arriving, Louis spiraled into respiratory distress, spurring doctors to rush him to the intensive care unit and place him on mechanical ventilation. There, a rapid-fire series of diagnostic tests revealed an escalating crisis. Louis had lymphoma, a cancer that affects the bodyâs pathogen-fighting lymphatic system. Unnoticed, the cancer had spread, eventually sending him into shock as his organs began to shut down.Soon after, several young doctors heard an alarm for the hospitalâs cardiology unit.
It was Louis. Unconscious and already fighting for his life, Louis was now facing another dire prognosis. The electrocardiogram monitoring his heart had flagged a possible heart attack.Code STEMI Hartaj Girn, at the time a senior cardiology fellow at USC, moved quickly, preparing for a potentially life-saving trip to the cardiac catheterization lab. There, doctors could open his blocked artery before too much damage occurred.
The emergency the team thought they were responding to, called an ST-segment elevation myocardial infarction, or STEMI, is one of the most serious crises for a patient. ÂGenerally, if thereâs a STEMI patient, it needs to be addressed very urgently. Itâs a really severe heart attack,â Girn says.A STEMI is usually distinguished by a characteristic aberration on the reading from an EKG machine, which measures the electric activity of the heart muscles. Where there should have been a flat line on Louisâs EKG monitor, there was now a marked upward swoop â a classic STEMI.An EKG reading like Louis had is normally all a doctor needs to authorize a catheterization procedure.
A probe is inserted into a patientâs veins and used to clear out the blockage thatâs starving the heart of life-giving oxygen. In making the decision, doctors are keenly aware of cardiologyâs golden rule. ÂTime is muscle.â Every second that slips away while a patient is having a heart attack means more dead tissue and a progressively worse prognosis. During a STEMI, erring on the side of caution is almost always a good idea.But something made Girn pause.
After three years in the organized chaos of a rapid-response cardiology unit, heâd learned to recognize a classic heart attack patient. And something didnât add up.Red Alert ReversalThough he was seriously ill, Louis, a man in his early 40s, had no real history of cardiovascular problems. And his vital signs, apparent STEMI aside, didnât scream âheart attack,â either. Doctors would normally be able to help address the confusion with a few questions to a patient, but Louis was sedated by powerful drugs â he wasnât waking up any time soon.(Credit.
Kellie Jaeger/Discover) Thinking quickly, Girn asked for an uasound machine to get a better look at Louisâ heart. By using a probe that emits sonic waves, an uasound can reproduce a moving image of the bodyâs interior. A heart in crisis will often move sluggishly on one side, starved of oxygen. But Louisâ heart looked fine.Girn moved the probe down, to get a look at the heart from below.
He pushed on Louisâ abdomen as he did, noting how oddly swollen it was. But that peculiarity vanished from his mind as one of the residents in the room pointed out something else strange. Louisâ EKG reading, which had brought them all running just minutes before, had suddenly returned to normal. Girn was dumbfounded.
ÂSTEMIs donât go away with putting a probe on somebodyâs chest.â He recalls thinking to himself jokingly, âI cured a STEMI with my hands.âPuzzled, he lifted the uasound probe off of Louisâ stomach. What had initially appeared to be a STEMI flashed back onto the screen, just as before. Girn repeated the motion a few times â watching what looked like a heart attack appear and disappear before his eyes. It was something without any real precedent, but, Girn says, it made one decision easier.
He cancelled the cath lab transfer, confident that Louis wasnât in immediate danger. But that didnât clear up the bigger question. If it wasnât a heart attack, what was going on?. Searching for Clues Girn went back to the cardiac cath room and gathered his team, including the attending cardiologist, Enrique Ostrzega, for a brief conference.
They knew that, in some rare cases, what appears to be a STEMI can actually be caused by something else â odd EKG readings might be the result of pneumonia, pancreatitis, intestinal bloating and a few other things.Ostrzega knew almost immediately that Girn made the right decision in keeping Louis out of the cath lab. A cardiac catheterization isnât an especially dangerous procedure, but a small percentage of patients still risk bleeding, stroke and kidney damage. And Louis, whose organs were already compromised, was at special risk from the contrast dye doctors inject during the procedure to check blood flow.âThis contrast agent could have made his kidney failure even worse,â Ostrzega says. ÂSo the price to pay for a procedure that is inadequate, or for the wrong diagnosis, is not minimal.âBut Louis was still in serious danger, as his body struggled to survive even with the help of modern medical technology.
It was imperative to figure out this new wrinkle, fast.Ostrzega focused the team on Louisâ abdomen. They knew it was severely swollen from an ileus, in which the normal movement of the gut comes to a standstill. Itâs not an uncommon occurrence on patients who are seriously ill. The ileus was causing gas to back up throughout his gastrointestinal tract, distending his abdomen.
The doctors recalled a few scattered reports that mentioned odd EKG readings as the result of gastric distention, a clue they could be on the right track. But there was nothing in the medical literature that explained exactly what they were dealing with.Next, the team reviewed an abdominal X-ray that had been done shortly before. Large dark blobs floated in the middle of Louisâ gut, indicating empty space in the negative coloration of an X-ray. The pressure was so severe, in fact, that his internal organs had been pushed around inside his abdomen, displaced by the gas pockets.
Could this be what was affecting his heart?. To test their hypothesis, the cardio doctors had the ICU team release the trapped air using a nasal tube. Sure enough, Louisâ EKG reading went back to normal. The supposed heart attack was nothing more than a bad case of bloating.Learning to ExhaleWhen food passing through the intestinal tract gets blocked, it can cause gas to back up in the abdominal cavity.
The bloating can be severe, so much so that some patients can appear to be pregnant. An ileus occurs when the intestines lose the ability to contract and keep food moving through. They can occur after surgeries on the intestines, as a side effect of powerful opioid pain relievers, or in patients like Louis, whose bodies are beginning to shut down.The cure for abdominal bloating, thankfully, is usually simple. A tube inserted into the intestines through the mouth or nose is typically enough to release the trapped air.For Girn, it was a lesson in trusting his instincts.
ÂEverything didnât add up the way it often does,â he says. That sliver of subconscious doubt made him take a step back, adding crucial seconds that ultimately led to the right call. The cardiology team wrote up their patientâs case in the Journals of the American College of Cardiology, possibly the first-ever report of a physical maneuver directly reversing STEMI elevations on an EKG.Though Louis benefitted from the doctorsâ speedy diagnosis, itâs an unfortunate reality that simply solving a medical mystery isnât always enough to save someoneâs life. Louis ultimately succumbed to his lymphoma.
But Girnâs instincts and rapid action spared his patient from an unnecessary invasive procedure that could have added to Louisâ distress. And the case is an important addition to the body of medical knowledge.âThings arenât as clear-cut as I thought before,â adds Girn. Now, heâs learned that âregardless of how little time you feel you have for a decision, look at the patient and try to make clinical sense of it.â Those few moments of thought might end up making all the difference. Nathaniel Scharping is a freelance science writer based in Tacoma, Washington.
The cases described in Vital Signs are real, but names and certain details have been changed..
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Latest hair loss News Can you get viagra without a prescription By Denise Mann HealthDay long term effects of propecia ReporterWEDNESDAY, Dec. 1, 2021 (HealthDay News) Asthma is a tough disease for kids and their parents to manage well, but not keeping it under control may make these children up to six times more likely to wind up in the hospital with severe hair loss treatment, new research shows. With the cold and flu season about to kick in and hair loss treatment rates climbing again in some areas, kids long term effects of propecia with asthma should make sure their disease is under tight control, said study author Aziz Sheikh. He is the director of the University of Edinburgh's Usher Institute, in Scotland. "It is also important that they are offered an additional layer of protection through being vaccinated against hair loss treatment," he added.
For the study, the researchers analyzed data on about 750,000 kids aged 5 to 17, including 63,463 with asthma, long term effects of propecia from March 2020 to July 2021. Poorly controlled asthma was defined as a previous hospitalization for asthma or being prescribed at least two courses of oral steroids to treat an asthma flare during the past two years. After controlling for other factors known to increase the risk of serious hair loss treatment, including certain underlying illnesses, children who had recently been hospitalized with asthma were six times more likely to be admitted to hospital with hair loss treatment, while those who had recently been prescribed oral steroids were three times more likely to be hospitalized with severe hair loss treatment than kids without asthma. Kids with poorly controlled asthma were also more likely to be hospitalized long term effects of propecia for hair loss treatment than those with well-controlled asthma, the study found. Still, serious complications from hair loss treatment are rare in kids, including those with asthma.
Just one in 380 children with poorly controlled asthma in the study was hospitalized with hair loss treatment, the findings showed. Exactly why kids with poorly controlled asthma are harder hit by hair loss treatment than other kids is not fully long term effects of propecia understood yet. "It may be because these children have inflamed airways from their sub-optimally controlled asthma and are more liable to adverse effects if exposed to the hair loss propecia," Sheikh suggested. The findings were published long term effects of propecia online Nov. 30 in The Lancet Respiratory Medicine journal.
The implications of this study are clear, said Rachel Harwood, a pediatric surgical registrar at Alder Hey Children's Hospital in Liverpool. "We advise that all children who are eligible to receive the flu treatment do so and that children [and their families] ensure that they continue to take long term effects of propecia their asthma medication and use a spacer to take any inhalers," said Harwood, who wrote an editorial accompanying the new research. (A spacer is a device that can help get more asthma medicine into the lungs.) What's more, children who are due to have an asthma review or whose asthma seems to be getting worse should make an appointment to see their doctor to ensure that they are receiving the correct treatment. It's not that children with asthma are at higher risk for severe hair loss treatment, it's kids who have poorly controlled asthma who are at risk, said Dr. William Sheehan, long term effects of propecia an allergist and immunologist at Children's National Hospital in Washington, D.C.
This suggests there is a window of opportunity to prevent complications from hair loss treatment for these kids, Sheehan said. Schedule a check-in with your child's doctor to get a head start on propecia season, he suggested. "Use this visit to make sure that your child has all the proper asthma long term effects of propecia medications and refills and is using them correctly," he said. "If they are not working, your doctor can adjust the doses or switch medications for better asthma control." Children with poorly controlled asthma should also be prioritized when it comes to receiving hair loss treatments, he said. In the United States, long term effects of propecia hair loss treatments are authorized for kids aged 5 and up.
More information The American Academy of Pediatrics offers tips on creating an asthma action plan for your child. SOURCES. Aziz Sheikh, director, University of long term effects of propecia Edinburgh's Usher Institute, Scotland. William Sheehan, MD, allergist, immunologist, Children's National Hospital, Washington, D.C.. Rachel Harwood, pediatric surgical registrar, Alder Hey Children's Hospital, Liverpool, U.K..
The Lancet Respiratory long term effects of propecia Medicine, Nov. 30, 2021, online Copyright © 2021 HealthDay. All rights reserved..
Latest hair loss News By Denise Mann here are the findings HealthDay price of propecia in canada ReporterWEDNESDAY, Dec. 1, 2021 (HealthDay News) Asthma is a tough disease for kids and their parents to manage well, but not keeping it under control may make these children up to six times more likely to wind up in the hospital with severe hair loss treatment, new research shows. With the cold and flu season about to kick in and hair loss treatment rates climbing again in some areas, kids with asthma should make sure their disease is under tight control, said study author Aziz price of propecia in canada Sheikh. He is the director of the University of Edinburgh's Usher Institute, in Scotland. "It is also important that they are offered an additional layer of protection through being vaccinated against hair loss treatment," he added.
For the study, the researchers analyzed data on about 750,000 kids aged 5 to price of propecia in canada 17, including 63,463 with asthma, from March 2020 to July 2021. Poorly controlled asthma was defined as a previous hospitalization for asthma or being prescribed at least two courses of oral steroids to treat an asthma flare during the past two years. After controlling for other factors known to increase the risk of serious hair loss treatment, including certain underlying illnesses, children who had recently been hospitalized with asthma were six times more likely to be admitted to hospital with hair loss treatment, while those who had recently been prescribed oral steroids were three times more likely to be hospitalized with severe hair loss treatment than kids without asthma. Kids with price of propecia in canada poorly controlled asthma were also more likely to be hospitalized for hair loss treatment than those with well-controlled asthma, the study found. Still, serious complications from hair loss treatment are rare in kids, including those with asthma.
Just one in 380 children with poorly controlled asthma in the study was hospitalized with hair loss treatment, the findings showed. Exactly why price of propecia in canada kids with poorly controlled asthma are harder hit by hair loss treatment than other kids is not fully understood yet. "It may be because these children have inflamed airways from their sub-optimally controlled asthma and are more liable to adverse effects if exposed to the hair loss propecia," Sheikh suggested. The findings price of propecia in canada were published online Nov. 30 in The Lancet Respiratory Medicine journal.
The implications of this study are clear, said Rachel Harwood, a pediatric surgical registrar at Alder Hey Children's Hospital in Liverpool. "We advise that all children who are eligible to receive the flu treatment do so and that children price of propecia in canada [and their families] ensure that they continue to take their asthma medication and use a spacer to take any inhalers," said Harwood, who wrote an editorial accompanying the new research. (A spacer is a device that can help get more asthma medicine into the lungs.) What's more, children who are due to have an asthma review or whose asthma seems to be getting worse should make an appointment to see their doctor to ensure that they are receiving the correct treatment. It's not that children with asthma are at higher risk for severe hair loss treatment, it's kids who have poorly controlled asthma who are at risk, said Dr. William Sheehan, an allergist and price of propecia in canada immunologist at Children's National Hospital in Washington, D.C.
This suggests there is a window of opportunity to prevent complications from hair loss treatment for these kids, Sheehan said. Schedule a check-in with your child's doctor to get a head start on propecia season, he suggested. "Use this visit to make sure that your child has all price of propecia in canada the proper asthma medications and refills and is using them correctly," he said. "If they are not working, your doctor can adjust the doses or switch medications for better asthma control." Children with poorly controlled asthma should also be prioritized when it comes to receiving hair loss treatments, he said. In the United States, price of propecia in canada hair loss treatments are authorized for kids aged 5 and up.
More information The American Academy of Pediatrics offers tips on creating an asthma action plan for your child. SOURCES. Aziz Sheikh, price of propecia in canada director, University of Edinburgh's Usher Institute, Scotland. William Sheehan, MD, allergist, immunologist, Children's National Hospital, Washington, D.C.. Rachel Harwood, pediatric surgical registrar, Alder Hey Children's Hospital, Liverpool, U.K..
The Lancet price of propecia in canada Respiratory Medicine, Nov. 30, 2021, online Copyright © 2021 HealthDay. All rights reserved..
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The NSW Government has announced the site for the $300 million Rouse Hill Hospital, to be built on the north-eastern side of Windsor Road.Health Minister Brad Hazzard said the new site, located near Commercial propecia pills amazon Road, ensures ideal transport and road links for Western Sydneyâs growing population.âI want to thank the local community for their patience as the experts have worked through a number of challenging obstacles to select a site which will offer the best outcome for the people of Rouse Hill and Western Sydney,â Mr Hazzard said.âI am thrilled to see us move to the next stage in delivering this vital health infrastructure project. The final propecia pills amazon site has better access and allows for more land use opportunities compared with the previously announced site, and allows us to better meet the future health needs of Western Sydney.â Member for Riverstone Kevin Conolly said the new hospital will be a tremendous asset for generations.âI am excited that we are still on track to get construction underway before the next election. To have a new hospital built in the right location is what our communities deserve,â Mr Conolly said.Member for propecia pills amazon Castle Hill Ray Williams said it would be a huge advantage for our patients, staff and carers to have good connectivity to the Rouse Hill Town Centre and a Sydney Metro station so close.âGood public transport and road access is essential.
Not just for patients and their families but also for the thousands of staff who will get jobs at this new hospital,â Mr Williams said.The site acquisition process is underway and construction will start in propecia pills amazon this term of Government, prior to March 2023. The NSW Government has committed $10.7 billion in health infrastructure propecia pills amazon investment over four years. Since 2011, the NSW Government has completed more than 150 health capital projects across the state..
The NSW Government has announced the site for the $300 million Rouse Hill Hospital, to be built on the north-eastern side of Windsor Road.Health Minister Brad Hazzard said the new site, located near Commercial Road, ensures ideal transport and road links for Western Sydneyâs growing population.âI want to thank the local community for their patience as the experts have worked through a number of challenging obstacles to select a site which will offer the best outcome price of propecia in canada for the people of Rouse Hill and Western Sydney,â Mr Hazzard said.âI am thrilled to see us move to the next stage in delivering this vital health infrastructure project. The final site has better access and allows for more land use opportunities compared with the previously announced site, and allows us to better meet the future health needs of Western Sydney.â Member for Riverstone Kevin Conolly said price of propecia in canada the new hospital will be a tremendous asset for generations.âI am excited that we are still on track to get construction underway before the next election. To have a new hospital built in the right location is what our communities deserve,â Mr Conolly said.Member for Castle Hill Ray Williams said it would be a huge advantage for our patients, staff and carers to have good connectivity to the Rouse Hill Town Centre and a Sydney Metro station so close.âGood public transport and road access price of propecia in canada is essential. Not just for patients and their families but also for the thousands of staff who will get price of propecia in canada jobs at this new hospital,â Mr Williams said.The site acquisition process is underway and construction will start in this term of Government, prior to March 2023.
The NSW Government price of propecia in canada has committed $10.7 billion in health infrastructure investment over four years. Since 2011, the NSW Government has completed more than 150 health capital projects across the state..
Propecia withdrawal
How to cite browse around here this article:Singh OP propecia withdrawal. Mental health in diverse India. Need for advocacy propecia withdrawal. Indian J Psychiatry 2021;63:315-6âUnity in diversityâ - That is the theme of India which we are quite proud of. We have propecia withdrawal diversity in terms of geography 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 propecia withdrawal toward women, health infrastructure, child mortality, and other sociodemographic development indexes. There is now ample evidence that sociocultural factors influence mental health. Compton and Shim[1] have described in their model of gene environment interaction how public policies and social norms act on the distribution of opportunity leading to social inequality, propecia withdrawal 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 propecia withdrawal 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 propecia withdrawal 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 propecia withdrawal of 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 propecia withdrawal indicator contrary to the western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders.
The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions. Apart from culture bound syndromes, the role propecia withdrawal of cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 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 propecia withdrawal 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 propecia withdrawal technical evidence for mapping out the problem, cost-effective interventions, 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 propecia withdrawal includes the National Mental Health Survey, National Survey on Extent and Pattern of Substance Use in India, Global Burden of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers.
Similarly, at propecia withdrawal organizational level, the Indian Psychiatric Society (IPS) has filed a case for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from 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 persons propecia withdrawal 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 propecia withdrawal highlighting the role of these factors on mental health. References 1.Compton MT, Shim RS. The social determinants propecia withdrawal of mental health. Focus 2015;13:419-25. 2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al.
National Mental Health Survey of propecia withdrawal 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. 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. 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. 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 ± 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. In. Sathyanarayana Rao TS, Tandon A, editors.
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Oman Med J 2017;32:251-5. 17.Rao TS. Comprehensive Study of Prevalence Rates, Symptom Profile, Comorbidity and Management of Dhat Syndrome in Rural and Urban Communities. PhD Thesis. Department of Psychiatry, Jagadguru Sri Shivarathreeshwara Medical College, JSS University, Shivarathreeshwara Nagar Mysore, Karnataka, India.
2017. 18.Kar SK. Treatment - emergent Dhat syndrome in a young male with obsessive-compulsive disorder. An alarm for medication nonadherence. Acta Med Int 2019;6:44-45.
[Full text] 19.Kuchhal AK, Kumar S, Pardal PK, Aggarwal G. Effect of Dhat syndrome on body and mind. Int J Contemp Med Res 2019;6:H7-10. 20.Shakya DR. Dhat syndrome.
Study of clinical presentations in a teaching institute of eastern Nepal. J Psychosexual Health 2019;1:143-8. 21.Leff JP. Culture and the differentiation of emotional states. Br J Psychiatry 1973;123:299-306.
22.Tiwari SC, Katiyar M, Sethi BB. Culture and mental disorders. An overview. J Soc Psychiatry 1986;2:403-25. 23.Sameer M, Menon V, Chandrasekaran R.
Is 'Pure' Dhat syndrome a stable diagnostic entity?. A naturalistic long term follow up study from a tertiary care centre. J Clin Diagn Res 2015;9:C01-3. 24.Chadda RK. Dhat syndrome.
Is it a distinct clinical entity?. A study of illness behaviour characteristics. Acta Psychiatr Scand 1995;91:136-9. 25.Bhatia MS, Bohra N, Malik SC. 'Dhat' syndrome â A useful clinical entity.
Indian J Dermatol 1989;34:32-41. 26.Dewaraja R, Sasaki Y. Semen-loss syndrome. A comparison between Sri Lanka and Japan. American J Psychotherapy 1991;45:14-20.
27.Balhara YP. Culture-bound syndrome. Has it found its right niche?. Indian J Psychol Med 2011;33:210-5. [PUBMED] [Full text] 28.Prakash, S, Mandal P.
Is Dhat syndrome indeed a culturally determined form of depression?. Indian J Psychol Med 2015;37:107-9. 29.Prakash O, Kar SK. Dhat syndrome. A review and update.
J Psychosexual Health 2019;1:241-5. 30.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al. Comorbidity in patients with Dhat syndrome. A nationwide multicentric study. J Sex Med 2015;12:1398-401.
31.Dhikav V, Aggarwal N, Gupta S, Jadhavi R, Singh K. Depression in Dhat syndrome. J Sex Med 2008;5:841-4. 32.Paris A. Dhat syndrome.
A review. Transcult Psychiatry Rev 1992;29:109-18. 33.Deb KS, Balhara YP. Dhat syndrome. A review of the world literature.
Indian J Psychol Med 2013;35:326-31. [PUBMED] [Full text] 34.Udina M, Foulon H, Valdés M, Bhattacharyya S, MartÃn-Santos R. Dhat syndrome. A systematic review. Psychosomatics 2013;54:212-8.
35.Kar SK, Sarkar S. Dhat syndrome. Evolution of concept, current understanding, and need of an integrated approach. J Hum Reprod Sci 2015;8:130-4. [PUBMED] [Full text] 36.World Health Organisation.
The ICD-10, Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. Geneva. World Health Organisation. 1992.
37.Perme B, Ranjith G, Mohan R, Chandrasekaran R. Dhat (semen loss) syndrome. A functional somatic syndrome of the Indian subcontinent?. Gen Hosp Psychiatry 2005;27:215-7. 38.Wig NN.
Problem of mental health in India. J Clin Soc Psychiatry 1960;17:48-53. 39.Clyne MB. Indian patients. Practitioner 1964;193:195-9.
40.Yap PM. The culture bound reactive syndrome. In. Caudil W, Lin T, editors. Mental Health Research in Asia and the Pacific.
Honolulu. East West Center Press. 1969. 41.Rao TS, Rao VS, Arif M, Rajendra PN, Murthy KA, Gangadhar TK, et al. Problems in medical practice.
A study on its prevalence in an outpatient setting. Indian J Psychiatry 1997:Suppl 39:53. 42.Bhatia MS, Thakkur KN, Chadda RK, Shome S. Koro in Dhat syndrome. Indian J Soc Psychiatry 1992;8:74-5.
43.Priyadarshi S, Verma A. Dhat syndrome and its social impact. Urol Androl Open J 2015;1:6-11. 44.Nakra BR, Wig NN, Verma VK. A study of male potency disorders.
Indian J Psychiatry 1977;19:13-8. [Full text] 45.Behere PB, Natraj GS. Dhat syndrome. The phenomenology of a culture bound sex neurosis of the orient. Indian J Psychiatry 1984;26:76-8.
[PUBMED] [Full text] 46.Singh G. Dhat syndrome revisited. Indian J Psychiatry 1985;27:119-22. [PUBMED] [Full text] 47.Bhatia MS, Malik SC. Dhat syndrome â A useful diagnostic entity in Indian culture.
Br J Psychiatry 1991;159:691-5. 48.Bhatia MS, Choudhry S, Shome S. Dhat syndrome - Is it a syndrome of Dhat only?. J Ment Health Hum Behav1997;2:17-22. 49.Bhatia MS.
An analysis of 60 cases of culture bound syndromes. Indian J Med Sci 1999;53:149-52. [PUBMED] [Full text] 50.Morrone A, Nosotti L, Tumiati Mc, Cianconi P, Casadei F, Franco G. Dhat Syndrome. An Analysis of 18 Cases.
Paper Presented in 11th Congress of the European Academy of Dermatology &. Venerology. Prague. Czech. 2002.
51.Carstairs GM. Hinjra and jiryan. Two derivatives of Hindu attitudes to sexuality. Br J Med Psychol 1956;29:128-38. 52.Carstairs GM.
The Twice Born. Bloomington. Indiana University Press. 1961. 53.Carstairs GM.
Psychiatric problems of developing countries. Based on the Morison lecture delivered at the Royal College of Physicians of Edinburgh, on 25 May 1972. Br J Psychiatry 1973;123:271-7. 54.Sathyanarayana Rao TS. Some thoughts on sexualities and research in India.
Indian J Psychiatry 2004;46:3-4. [PUBMED] [Full text] 55.Prakash O, Rao TS. Sexuality research in India. An update. Indian J Psychiatry 2010;52:S260-3.
56.Avasthi A, Grover S, Rao TS. Clinical practice guidelines for management of sexual dysfunction. Indian J Psychiatry 2017;59 Suppl 1:S91-115. 57.Kavanoor Sridhar V, Subramanian K, Menon V. Current nosology of Dhat syndrome and state of evidence.
Indian J Health Sex Cult 2018;4:8-14. 58.APA (American Psychological Association). Diagnostic and Statistical Manual of Mental Disorders. DSM-5. Washington.
DC. American Psychological Association. 2013. 59.Yasir Arafat SM. Dhat syndrome.
Culture bound, separate entity, or removed. J Behav Health 2017;6:147-50. 60.Prakash S, Sharan P, Sood M. A qualitative study on psychopathology of dhat syndrome in men. Implications for classification of disorders.
Asian J Psychiatr 2018;35:79-88. 61.Lewis-Fernández R, Aggarwal NK. Culture and psychiatric diagnosis. Adv Psychosom Med 2013;33:15-30. 62.Sharan P, Keeley J.
Cultural perspectives related to international classification of diseases-11. Indian J Soc Psychiatry 2018;34 Suppl S1:1-4. Correspondence Address:T S Sathyanarayana RaoDepartment of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka IndiaSource of Support. None, Conflict of Interest. NoneDOI.
10.4103/psychiatry.IndianJPsychiatry_791_20.
How to price of propecia in canada cite this article:Singh OP. Mental health in diverse India. Need for price of propecia in canada 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 to the deserts to the price of propecia in canada seas. Every region has its own distinct culture and food. There are so many varieties of dress and language. There is huge difference between the states in terms of development, attitude toward women, health infrastructure, child mortality, and price of propecia in canada other sociodemographic development indexes.
There is now ample evidence that sociocultural factors influence mental health. Compton and Shim[1] have described in their model price of propecia in canada of gene environment interaction how public policies and social norms act on the distribution of opportunity leading to social inequality, exclusion, poor environment, discrimination, and unemployment. This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and early brain insult with low access to health care leads to poor mental health, disease, and morbidity.When price of propecia in canada we come to the field of mental health, we find huge differences between different states of India.
The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed northern states had more of childhood price of propecia in canada onset disorders. This may be due to lead toxicity, nutritional status, and perinatal issues.
Higher rates of depression and anxiety were found in females price of propecia in canada. 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 price of propecia in canada norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders.
The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions. Apart from culture bound syndromes, the role of cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower price of propecia in canada 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 price of propecia in canada require sustained advocacy aimed at promoting rights of mentally ill persons and reducing stigma and discriminations.
It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population. Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and pathways should be to build technical evidence for mapping out the problem, cost-effective interventions, and their efficacy.Advocacy can be done at institutional level, organizational level, and individual price of propecia in canada level. There has been huge work done in this regard at institution level.
Important research price of propecia in canada 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 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 filed a case for lacunae in Mental Health-care Act, 2017 price of propecia in canada. 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 price of propecia in canada with editorials highlighting the need of care of marginalized population such as migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy is economic inequality, our weapon is research price of propecia in canada highlighting the role of these factors on mental health.
References 1.Compton MT, Shim RS. The social price of propecia in canada 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 price of propecia in canada 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.
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.
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.
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 ± 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. In.
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How much does propecia cost at walmart
Clear evidence for a weekend effect was first demonstrated by Bell and Redelmeier1 who examined how much does propecia cost at walmart 3.8âmillion emergency admissions http://www.abfischfest.at/juliam-2/angebote-zum-abfischfest/ between 1988 and 1997 in an acute care hospital in Ontario. They had noted that staffing levels were lower in acute care hospitals how much does propecia cost at walmart at weekends and hypothesised that this might lead to poorer care and higher mortality. To test this hypothesis, they identified three conditions (ruptured abdominal aortic aneurysm, acute epiglottitis and pulmonary embolism) for which lower staffing on admission was expected to have consequences in outcomes, as well as three control conditions for which this would not be the case.
In addition, they conducted an analysis without a prespecified hypothesis, examining the 100 conditions responsible for most how much does propecia cost at walmart deaths. After adjustment for illness severity, they found higher mortality for conditions expected to be affected by lower staffing and no increase for control conditions. From the 100 medical conditions examined, how much does propecia cost at walmart 23 had significantly increased mortality risk for weekend admissions.
These two sets of findings provided strong evidence for a weekend effect, suggesting that for some conditions lower staffing on admission affected standards of care and thereby patient outcomes.Since then, dozens of studies of the weekend effect have been conducted, mostly in the UK and the USA.2 In Britain, the issue became much more high profile after an intervention in 2015 by the Secretary of State who suggested that 11â000 patients were unnecessarily dying at the weekend.3 4 This claim was challenged at the time,5 and many pointed out that the National Health Service (NHS) was already a 7-day service.6 7 However, concern about the weekend led eventually to the introduction of â7âday servicesâ in the NHS in England. A new set of 10 clinical standards was introduced to reduce differences between weekend and weekday services, including how much does propecia cost at walmart increased involvement of consultants in the first 24 hours of admission.8 9 A cross-sectional analysis covering the period before introduction showed no association between specialist intensity and weekend admission mortality.10 Nevertheless, the programme did lead to many NHS hospital trusts reorganising services to reduce differences in care delivery across the 7-day week. The reorganisation of services did not affect clinical outcomes11 nor was adoption of the clinical standards associated with any significant change in the magnitude of the weekend effect.12Possible underlying mechanisms.
The weekend as proxy variableRecent systematic reviews have concluded that the weekend effect does exist, but the explanation for the finding is unclear.2 4 13â17 Patients admitted to hospital at the weekend are more likely to die than those during weekdays with ORs of 1.16 how much does propecia cost at walmart (all studies)2 and 1.07 (UK studies),4 with reviews for some specific disease categories reporting higher ORs.2 13 The quality of studies is highly variable, with findings being influenced by methodological, clinical and service configuration factors2 with ongoing debate about likely mechanisms. Why has it been so difficult to elucidate possible mechanisms?. To go more deeply into this, we need to consider what role the weekend is playing in the design of all these studies.Bell and Redelmeier1 used two distinct designs in their original investigation, which might best be defined as how much does propecia cost at walmart an investigation of staffing levels and mortality.
In their first analysis, the weekend is used as a proxy measure for differences in staffing. They targeted specific conditions such as ruptured abdominal aortic aneurysm for which staffing on admission was deemed likely to have an important how much does propecia cost at walmart impact on patient outcomes. Their second analysis took the opposite approach, by examining overall outcomes at the weekend and then speculating about which factors might explain any observed differences.
Most subsequent studies have used the second approach, which has made it difficult to make progress on identifying the relevant how much does propecia cost at walmart factors driving any effect. If we do not define the questions and hypothesised relationships precisely, then we will not be able to identify how care delivered to patients is affected and which factors are responsible for poorer outcomes. Critically, if we how much does propecia cost at walmart cannot identify the factors, then we cannot intelligently propose interventions to improve patient care.We therefore need to examine how the weekend as a proxy variable for staffing levels fits into the conceptual model.
Is the proxy only associated with the determinant, often assumed to be staffing levels, or also with other possible confounders or factors that affect the outcome in question?. We recognise there are multiple possible sets of relationships, but examining three of them how much does propecia cost at walmart is sufficient to make the general argument. Figure 1 displays three possible sets of relationships, which correspond with three broad hypotheses about potential mechanisms and hence the interpretation of the weekend effect.Proxy measures in the context of studying a determinant - outcome relationship, applied to the weekend as a proxy variable for staffing." data-icon-position data-hide-link-title="0">Figure 1 Proxy measures in the context of studying a determinant - outcome relationship, applied to the weekend as a proxy variable for staffing.Levels of staffing on admission is the dominant influence on quality of care and mortality (panel A)This shows the âidealâ and simplest situation when the proxy weekend/weekday variable is primarily associated with staffing in the first hours or days.
The implied mechanism is that lower numbers of staff, particularly senior staff, lead to poorer how much does propecia cost at walmart care and increased mortality. In that situation, weekendâweekday mortality differences, after adjustment for patient mix, can be presumed to be due to staffing differences. Bell and Redelmeier specifically tested this scenario by selecting those conditions for which the first few days of admission are critical, that are treatable and where death may be rapid how much does propecia cost at walmart.
For these conditions, insufficient staffing levels at admission (determinant) might cause delay in care processes (intermediate variable) and higher mortality (outcome).Patients at weekends are sicker and more likely to die (panel B)As many studies have shown, the weekend is associated with confounding variables. Patients admitted at the weekend are known to be sicker18 19 and are less likely to be admitted from emergency departments despite attendance rates being similar.16 20 Studies attempt to control for severity of condition and other confounders, but there is general agreement that it is simply not possible to control for how much does propecia cost at walmart all potential factors (and confounding by indication). There is always the possibility that, even after adjustment for severity of how much does propecia cost at walmart illness and other patient variables, that differences in outcome are due to other patient factors that, for whatever reason, could not be included in the calculations.
So for many conditions, this is an important alternative pathway to consider.Multiple factors affect care at the weekend, which in turn increases mortality (panel C)This model underlies the second approach by Bell and Redelmeier and many subsequent studies. The basic hypothesis is how much does propecia cost at walmart that patient outcomes differ between weekend and weekday, but this may be due to multiple relationships and multiple interrelated variables. For instance, the average seniority or specialty level may differ between the groups of nurses and medical staff working during weekdays and weekends, and such differences in skill-mix may affect patient outcomes.21â23 Access to diagnostic tests or other ancillary services might also differ between weekends and weekdays, or there may be factors further along the patient pathway (in subsequent days after admission) such as how quickly any deterioration on the ward is detected.
In this scenario, uncertainty about the mechanisms of the weekend effect makes it very difficult how much does propecia cost at walmart to identify targeted interventions to improve outcomes for patients admitted at the weekend.The assumed intermediate variable of worse quality of careHypotheses 1 and 3 have the same intermediate variable, that quality of care is poorer at the weekendâalthough for different reasonsâand that this is the reason for higher mortality. Investigating this particular proposal requires, as many have noted, âpainstaking detective workâ,24 but few studies have directly examined the quality of care provided during weekdays and at weekends. In this issue of how much does propecia cost at walmart BMJ Quality &.
Safety, Bion and colleagues therefore add crucial evidence with their impressive and comprehensive study.25 They reviewed the quality of care delivered by examining case records from 4000 non-operative medical emergency admissions in 20 acute hospital trusts before and after introduction of the â7-day servicesâ in England. Records were randomly sampled from each trust, equally divided between the two time periods and weekend versus weekday admissions how much does propecia cost at walmart. They found that rates of errors and adverse events were not significantly different between weekdays and weekends and that this was the case both before and after introduction of the â7-day servicesâ.
They also made a direct assessment of intensity of senior medical staffing by comparing hours of how much does propecia cost at walmart consultant time per 10 emergency admissions between Sundays and Wednesdays. This specialist intensity ratio was much lower at weekends (0.51 overall) and improved slightly (from 0.47 to 0.58) across periods. Their study therefore does not offer support for quality of care being worse at the weekend how much does propecia cost at walmart or that senior staff involvement at an early point in the patientâs admission is significantly associated with overall quality of care.
We should note, however, that operative patients were excluded, so it remains possible that care is poorer for some other groups of patients.The implicit assumption in many previous studies, and most political discourse, is that the weekend is simply a reflection and proxy for lower levels of skilled staff, particularly medical staff. Proxy variables are of how much does propecia cost at walmart course used all the time in research and can be very helpful if they are âcloseâ to the variable of interest. For instance, we might use the prescription record of a medication as a proxy for the actual medication administered to the patient.
We are then confident of what the proxy means how much does propecia cost at walmart and how it relates to the actual variable of interest. Even though some patients may decide not to collect their medication or be non-adherent in taking it, interpreting the proxy is relatively straightforward.In contrast, the weekend/weekday comparison is a distant and complex proxy. Care could potentially be different for a whole variety of reasons, which are only partly dependent on levels of skilled medical how much does propecia cost at walmart staff.
Diagnostic tests and investigations may not be readily available. Coordination between different specialties may be problematic within the hospital how much does propecia cost at walmart or between primary and secondary care and so on. Each of these may cause delay in a care process that may (in combination) affect patient outcomes.
In addition, conditions vary in the how much does propecia cost at walmart extent to which delays in the first few days are critical in preventing death. Some primarily require skilled staff on admission, while others are more vulnerable to later deterioration on wards and need care from experienced nurses in the days following admission.Should we continue studying the weekend effect? how much does propecia cost at walmart. We do not doubt that studies of the weekend effect have been worthwhile.
Clearly, the higher mortality at how much does propecia cost at walmart weekends originally identified 20 years ago merited investigation. The question is whether it is worthwhile to continue to conduct similar studies in the future given the limited funding and research time available. What avenues of inquiry are most likely how much does propecia cost at walmart to benefit patients?.
The ultimate aim of all concerned is to improve care given to patients. The weekend effect is only important as a potential how much does propecia cost at walmart marker of other problems. Local reviews of mortality or other indices of quality should always be alert to variations in the quality of care over the week, and consider whether care is poorer at weekends or indeed at any particular time of the day, week or year.
However, we consider that there how much does propecia cost at walmart is no reason to carry out further studies that simply demonstrate a weekend effect. We need instead to turn our attention to the factors directly influencing quality of care for which the weekend has been a proxy.Bion and colleagues provide a valuable illustration of research that examines the presumed causal relationships, looking at the actual care processes and so give a clearer indication of what kind of intervention might most benefit patients. Their study found that care had improved over time but that about 15% of patients received partial care and a small percentage received very poor care.25 These problems occurred how much does propecia cost at walmart throughout the week, affecting the larger volume of patients treated on weekdays.
Following the example of the study by Bion et al, future studies could directly assess standards of care and the factors that most powerfully influence quality. A notable example is the study by Jayawardana and colleagues,26 showing that the increased mortality for out-of-hours admissions how much does propecia cost at walmart with ST-elevation acute myocardial infarction was explained by differences in door-to-needle time, identifying the specific care process on which interventions should be targeted. To improve clinical practice, we need evidence that will help us design targeted interventions to influence the quality of care delivered and thereby patient outcomes.The â7-day servicesâ initiative was introduced in England without a clear understanding of the causes of the weekend effect.
The intervention, while well intentioned, was how much does propecia cost at walmart therefore poorly targeted. Rather than a one-size-fits all initiative to increase consultant intensity, we should consider the much harder question on how to spend the same money to maximum effect. Consultant time how much does propecia cost at walmart is scarce and so should be tailored to the time, place and particular conditions where it is most beneficial over the week as a whole.
For some patients though, more rapid access to diagnostic tests or the increased use of skilled nurses during recovery may be much more critical to improving outcomes. Studies of the weekend effect drew attention to how much does propecia cost at walmart potentially dangerous levels of staffing that undoubtedly posed risks to patients. At this point, however, we need more precise studies that directly examine standards of care and the factors that influence the care delivered.
We can then define and target interventions effectively and make best use of scarce resources.Ethics statementsPatient consent for publicationNot required.The Harvard Medical Practice Study brought the issue of how much does propecia cost at walmart patient safety into the public eye and demonstrated that patients are often harmed by the care they receive.1 It used retrospective chart review to identify adverse events. Since its publication in 1991, considerable focus has been placed on trying to improve the methods for understanding the prevalence of harm in hospitals. These efforts have led to how much does propecia cost at walmart deeper understanding of the relative strengths and weaknesses of the tools we currently have for adverse event identification.
Still, most organisations do not have robust approaches for tracking all types of harm routinely. Other efforts have sought to assess safety not just in hospitals but across national health systems, and at one point in time, and to track and trend.Developing better approaches for measuring safety routinely is critical if we are to understand how many patients are being harmed, what the primary causes are and whether how much does propecia cost at walmart care is getting safer or less safe. However, it is also work that needs to be contextualised and the limitations of our tools must be appreciated.2 3The Irish National Adverse Event Study 2 (INAES-2) is presented in this issue.4 In this study, Connolly and colleagues used retrospective chart review to find adverse events at eight Irish hospitals how much does propecia cost at walmart in 2015 and compare these to previously reported data from 2009.
Retrospective chart review was the first method used in this space5 6 and is still a mainstay for national studies assessing rates of adverse events,7â12 although approaches using claims data are also used widely and are much less expensive though much less sensitive.13 The original approach using retrospective chart review relied on information exclusively gathered from retrospective review of randomly selected medical records, but it has since been bolstered by the creation of standardised triggers,14 and more rigorous methods for chart review which make it more sensitive for finding adverse events, and more reliable. Despite this, retrospective chart review has many limitations, most notably the level how much does propecia cost at walmart of agreement between abstractors and its reliance on the completeness of documentation in medical charts.15The issue of reliance on documentation is especially important. There have been well-conceived critiques that have raised concern related to underdocumentation of errors that occur in hospitals, as well as those that have raised concern that the findings from longitudinal studies looking at trends may be confounded by improved documentation resulting in an overestimation of the true (comparative) incidence of events.
These are both legitimate how much does propecia cost at walmart concerns. The INAES-2 study, as in prior similar work looking at multi-institution adverse event rates over time,16 17 showed an increase in events over time but no change in preventable harm. We are left not knowing how much does propecia cost at walmart if this represents a change in safety or a change in documentation.These concerns have led other investigators to develop adverse event identification approaches to enable more real-time identification, leveraging a broader set of data for the interpretation of the preventability and impact of these events.18 19 Prospective event identification, or the near real-time application of triggers, can also incorporate the perspectives of staff in the clinical environment around the time of the event to provide additional insights.
Even with this more comprehensive, contemporaneous collection of data however, agreement continues to be variable between reviewers.20â22Looking to spontaneous reporting from front-line staff, rather than retrospectively or prospectively monitoring for triggers, is another method that has been proposed as a mechanism for identifying the prevalence of adverse events over time. Similar to documentation, however, concerns exist about the under-reporting of events by front-line staff in safety reporting systems.23 24 Moreover, spontaneous reporting routinely underestimates the incidence of adverse events for some types of events how much does propecia cost at walmart by a factor of 20.25The inverse is also likely true that advances in safety culture may increase reporting, without any change in the frequency of actual events. Indeed, in the INAES-2 study, the researchers found that although safety reports increased threefold, adverse event rates did not change.
This highlights the challenge how much does propecia cost at walmart of using safety reports alone as a proxy for adverse events. Instead, the insights from safety reporting may hold promise for other uses in the safety space, such as providing a signal for the degree of staff engagement in safety, enabling the identification of near misses and facilitating the identification of significant events that require root cause analysis.Because of the variability that exists in the methods mentioned, many investigators have attempted to identify more reliable ways to identify adverse events. Several studies have employed reimbursement codes (in the USA, International Classification of Diseases Ninth Revision codes) as a mechanism to screen for adverse events.26â28 These systems, which aim to identify complications of medical care by looking for codes that are highly associated with adverse events, have largely been shown to be ineffective.29 30 This is likely to be multifactorial, with an inability to identify which conditions predated the current healthcare encounter, a lack of incentives to use coding to identify adverse events and their limited ability to accurately how much does propecia cost at walmart capture the full clinical picture all contributing to their limited efficacy.31Other approaches have leveraged information systems to screen for adverse events, which is almost certainly how this will be done in the future.32 This works better for some categories of events than for others.
Identification for some events is relatively straightforward, for example, for the development of acute kidney injury in which there is a biomarker to track (rise in creatinine), which routinely appears when the event is present. However, the how much does propecia cost at walmart identification of newly altered mental status, for example, is much more challenging. For events such as falls, which are almost always documented in electronic health record (EHR) systems, this also works well.
Commercial products how much does propecia cost at walmart that sift through data from the EHR are available to find adverse events for inpatients, while the situation regarding adverse event detection is much less advanced in the ambulatory setting, even though EHR use is widespread in developed countries. Among the main types of inpatient adverse events, hospital-acquired s, adverse drug events and falls can readily be detected in inpatients, while the situation is more complex for deep venous thromboses/pulmonary emboli, surgical injuries, specific types of pressure ulcers and missed diagnoses.32 Novel approaches that are highly effective for identifying wrong patient errors have been developed, such as âretract and reorderâ detection, which identifies these errors effectively.33 This has led to interventions such as showing the photograph of a patient to the ordering clinician, which reduced the likelihood of a wrong patient order by 43% in one study.34 Still, most organisations do not have a robust sense of how often their patients experience adverse events across the spectrum of care.The challenge of adverse event identification is multiplied by the importance of understanding one moment in time and, as the authors in the INAES-2 study aim to do, trying to look at trends. This will be essential as we continue to mobilise large efforts to how much does propecia cost at walmart improve safety and as these compete with other priorities.
As with all work in quality, having robust metrics is vital. In safety, how much does propecia cost at walmart however, we have in many ways been âflying blindââinitiating large-scale efforts to decrease the rate of adverse events without having reliable ways to measure their prevalence over time.It is important to emphasise that this lack of insight into performance is not equally distributed across all categories of adverse events.3 In fact, as proposed recently by Shojania and Marang-van de Mheen, the incidence of adverse events may be best understood as a composite measureâwith all of the limitations that come with looking at a measure with many composite parts.35 When broken apart, what we come to understand is that some of our mechanisms for identifying certain types of events are likely much more reliable than others. In the USA, for example, where the Agency for Healthcare Research and Quality has leveraged standardised methods for collecting and reporting national performance on a set of specific healthcare-associated s, we have much better insight into performance over time related to such healthcare-associated s than we do, for instance, with diagnostic error.Lastly, the challenge of interpreting national adverse event data over time is complicated by the nuances associated with the interfaces between politics and science.
In our personal experience, we have encountered challenges reporting results of safety studies that are tied to ministries of health.36 Related to the INAES-2 study specifically, Ireland has a long history of sensationalised media coverage of data pointing to opportunities for improved care, further complicating researchersâ ability to conduct this work free how much does propecia cost at walmart of influence.37Ultimately, the work presented by Connolly and colleagues is critically important work and we suggest that all health systems should be monitoring adverse event rates over time. The mechanisms for doing this, though, should rapidly evolve. With hospitals increasingly leveraging EHRs, data being collected in more uniform ways and advances in natural language processing and artificial intelligence, a future in which we have reliable measures of adverse events that are stable over time is likely within our reach how much does propecia cost at walmart.
To get from here to there, an ongoing investment in research with evaluation including leveraging artificial intelligence and natural language processing, and a commitment to transparent data reporting and enabling collaboration between organisations and governments focused on this work is essential.38 If we can achieve this, we could reasonably expect a future in which we have access to publicly available meaningful data on how many people are being harmed, and in what context, which could in turn transform safety.Ethics statementsPatient consent for publicationNot required..
Clear evidence price of propecia in canada for a weekend effect was first demonstrated by Bell and Redelmeier1 who examined 3.8âmillion emergency admissions between 1988 and 1997 in an acute care propecia finasteride buy hospital in Ontario. They had noted that staffing levels were lower in acute care hospitals at weekends and hypothesised that this might lead to price of propecia in canada poorer care and higher mortality. To test this hypothesis, they identified three conditions (ruptured abdominal aortic aneurysm, acute epiglottitis and pulmonary embolism) for which lower staffing on admission was expected to have consequences in outcomes, as well as three control conditions for which this would not be the case.
In addition, they conducted an analysis without a prespecified hypothesis, examining the 100 conditions responsible for most price of propecia in canada deaths. After adjustment for illness severity, they found higher mortality for conditions expected to be affected by lower staffing and no increase for control conditions. From the 100 medical conditions examined, 23 had significantly increased mortality price of propecia in canada risk for weekend admissions.
These two sets of findings provided strong evidence for a weekend effect, suggesting that for some conditions lower staffing on admission affected standards of care and thereby patient outcomes.Since then, dozens of studies of the weekend effect have been conducted, mostly in the UK and the USA.2 In Britain, the issue became much more high profile after an intervention in 2015 by the Secretary of State who suggested that 11â000 patients were unnecessarily dying at the weekend.3 4 This claim was challenged at the time,5 and many pointed out that the National Health Service (NHS) was already a 7-day service.6 7 However, concern about the weekend led eventually to the introduction of â7âday servicesâ in the NHS in England. A new set of 10 clinical standards was introduced to reduce differences between weekend and weekday services, including increased involvement of consultants in the first 24 hours of admission.8 price of propecia in canada 9 A cross-sectional analysis covering the period before introduction showed no association between specialist intensity and weekend admission mortality.10 Nevertheless, the programme did lead to many NHS hospital trusts reorganising services to reduce differences in care delivery across the 7-day week. The reorganisation of services did not affect clinical outcomes11 nor was adoption of the clinical standards associated with any significant change in the magnitude of the weekend effect.12Possible underlying mechanisms.
The weekend as proxy variableRecent systematic reviews have concluded that the weekend effect does exist, but the explanation for the finding is unclear.2 4 13â17 Patients admitted to hospital at the weekend are more likely to die than those during weekdays with ORs of 1.16 (all studies)2 and 1.07 (UK studies),4 with reviews for some specific disease categories reporting higher ORs.2 13 The quality of studies is highly variable, with price of propecia in canada findings being influenced by methodological, clinical and service configuration factors2 with ongoing debate about likely mechanisms. Why has it been so difficult to elucidate possible mechanisms?. To go price of propecia in canada more deeply into this, we need to consider what role the weekend is playing in the design of all these studies.Bell and Redelmeier1 used two distinct designs in their original investigation, which might best be defined as an investigation of staffing levels and mortality.
In their first analysis, the weekend is used as a proxy measure for differences in staffing. They targeted specific conditions such as ruptured abdominal aortic aneurysm for which staffing on admission was deemed likely to have an important impact price of propecia in canada on patient outcomes. Their second analysis took the opposite approach, by examining overall outcomes at the weekend and then speculating about which factors might explain any observed differences.
Most subsequent studies have price of propecia in canada used the second approach, which has made it difficult to make progress on identifying the relevant factors driving any effect. If we do not define the questions and hypothesised relationships precisely, then we will not be able to identify how care delivered to patients is affected and which factors are responsible for poorer outcomes. Critically, if we cannot identify the factors, then we cannot intelligently propose interventions to improve patient care.We therefore need to examine how the weekend as a proxy variable for price of propecia in canada staffing levels fits into the conceptual model.
Is the proxy only associated with the determinant, often assumed to be staffing levels, or also with other possible confounders or factors that affect the outcome in question?. We recognise there are multiple possible sets of relationships, but examining three of them is price of propecia in canada sufficient to make the general argument. Figure 1 displays three possible sets of relationships, which correspond with three broad hypotheses about potential mechanisms and hence the interpretation of the weekend effect.Proxy measures in the context of studying a determinant - outcome relationship, applied to the weekend as a proxy variable for staffing." data-icon-position data-hide-link-title="0">Figure 1 Proxy measures in the context of studying a determinant - outcome relationship, applied to the weekend as a proxy variable for staffing.Levels of staffing on admission is the dominant influence on quality of care and mortality (panel A)This shows the âidealâ and simplest situation when the proxy weekend/weekday variable is primarily associated with staffing in the first hours or days.
The implied mechanism is that lower numbers price of propecia in canada of staff, particularly senior staff, lead to poorer care and increased mortality. In that situation, weekendâweekday mortality differences, after adjustment for patient mix, can be presumed to be due to staffing differences. Bell and Redelmeier specifically tested this scenario by selecting those conditions for which the first few days of admission are critical, that are treatable and price of propecia in canada where death may be rapid.
For these conditions, insufficient staffing levels at admission (determinant) might cause delay in care processes (intermediate variable) and higher mortality (outcome).Patients at weekends are sicker and more likely to die (panel B)As many studies have shown, the weekend is associated with confounding variables. Patients admitted at the weekend are known to be sicker18 19 and are less likely to be admitted from emergency departments despite attendance rates being similar.16 20 Studies attempt to control for severity of condition and other confounders, but there is general agreement that it is simply not possible price of propecia in canada to control for all potential factors (and confounding by indication). There is always the possibility that, even after adjustment for severity of illness and other patient variables, that differences in outcome are due to price of propecia in canada other patient factors that, for whatever reason, could not be included in the calculations.
So for many conditions, this is an important alternative pathway to consider.Multiple factors affect care at the weekend, which in turn increases mortality (panel C)This model underlies the second approach by Bell and Redelmeier and many subsequent studies. The basic hypothesis is that patient outcomes differ between weekend and weekday, but this may be due price of propecia in canada to multiple relationships and multiple interrelated variables. For instance, the average seniority or specialty level may differ between the groups of nurses and medical staff working during weekdays and weekends, and such differences in skill-mix may affect patient outcomes.21â23 Access to diagnostic tests or other ancillary services might also differ between weekends and weekdays, or there may be factors further along the patient pathway (in subsequent days after admission) such as how quickly any deterioration on the ward is detected.
In this scenario, uncertainty about the mechanisms of the weekend effect makes it very difficult to identify targeted interventions to improve outcomes for patients admitted at the weekend.The assumed intermediate variable of worse quality of careHypotheses 1 and 3 have the same intermediate variable, that quality of care is poorer at the weekendâalthough for different reasonsâand that price of propecia in canada this is the reason for higher mortality. Investigating this particular proposal requires, as many have noted, âpainstaking detective workâ,24 but few studies have directly examined the quality of care provided during weekdays and at weekends. In this issue of price of propecia in canada BMJ Quality &.
Safety, Bion and colleagues therefore add crucial evidence with their impressive and comprehensive study.25 They reviewed the quality of care delivered by examining case records from 4000 non-operative medical emergency admissions in 20 acute hospital trusts before and after introduction of the â7-day servicesâ in England. Records were randomly sampled from each trust, price of propecia in canada equally divided between the two time periods and weekend versus weekday admissions. They found that rates of errors and adverse events were not significantly different between weekdays and weekends and that this was the case both before and after introduction of the â7-day servicesâ.
They also made a direct assessment of intensity of senior medical price of propecia in canada staffing by comparing hours of consultant time per 10 emergency admissions between Sundays and Wednesdays. This specialist intensity ratio was much lower at weekends (0.51 overall) and improved slightly (from 0.47 to 0.58) across periods. Their study price of propecia in canada therefore does not offer support for quality of care being worse at the weekend or that senior staff involvement at an early point in the patientâs admission is significantly associated with overall quality of care.
We should note, however, that operative patients were excluded, so it remains possible that care is poorer for some other groups of patients.The implicit assumption in many previous studies, and most political discourse, is that the weekend is simply a reflection and proxy for lower levels of skilled staff, particularly medical staff. Proxy variables are of course used all the time in research and can be very helpful if they are âcloseâ price of propecia in canada to the variable of interest. For instance, we might use the prescription record of a medication as a proxy for the actual medication administered to the patient.
We are then confident of what the proxy means price of propecia in canada and how it relates to the actual variable of interest. Even though some patients may decide not to collect their medication or be non-adherent in taking it, interpreting the proxy is relatively straightforward.In contrast, the weekend/weekday comparison is a distant and complex proxy. Care could potentially be different for a whole variety of price of propecia in canada reasons, which are only partly dependent on levels of skilled medical staff.
Diagnostic tests and investigations may not be readily available. Coordination between different specialties may be problematic within the hospital or price of propecia in canada between primary and secondary care and so on. Each of these may cause delay in a care process that may (in combination) affect patient outcomes.
In addition, conditions vary in the extent to which delays in price of propecia in canada the first few days are critical in preventing death. Some primarily require skilled staff on admission, while others are more vulnerable to later deterioration on wards and need care from experienced nurses in the days following price of propecia in canada admission.Should we continue studying the weekend effect?. We do not doubt that studies of the weekend effect have been walmart pharmacy propecia price worthwhile.
Clearly, the higher mortality at weekends originally identified 20 years ago price of propecia in canada merited investigation. The question is whether it is worthwhile to continue to conduct similar studies in the future given the limited funding and research time available. What avenues of inquiry price of propecia in canada are most likely to benefit patients?.
The ultimate aim of all concerned is to improve care given to patients. The weekend effect is only important as a potential marker of other problems price of propecia in canada. Local reviews of mortality or other indices of quality should always be alert to variations in the quality of care over the week, and consider whether care is poorer at weekends or indeed at any particular time of the day, week or year.
However, we consider that there is no reason to carry out further price of propecia in canada studies that simply demonstrate a weekend effect. We need instead to turn our attention to the factors directly influencing quality of care for which the weekend has been a proxy.Bion and colleagues provide a valuable illustration of research that examines the presumed causal relationships, looking at the actual care processes and so give a clearer indication of what kind of intervention might most benefit patients. Their study found that care had improved over time but that about 15% of patients received partial care and a small percentage received very price of propecia in canada poor care.25 These problems occurred throughout the week, affecting the larger volume of patients treated on weekdays.
Following the example of the study by Bion et al, future studies could directly assess standards of care and the factors that most powerfully influence quality. A notable example is the study by Jayawardana and colleagues,26 showing that the increased mortality for out-of-hours admissions with ST-elevation acute myocardial infarction was explained by differences in door-to-needle time, identifying price of propecia in canada the specific care process on which interventions should be targeted. To improve clinical practice, we need evidence that will help us design targeted interventions to influence the quality of care delivered and thereby patient outcomes.The â7-day servicesâ initiative was introduced in England without a clear understanding of the causes of the weekend effect.
The intervention, while well intentioned, was therefore poorly price of propecia in canada targeted. Rather than a one-size-fits all initiative to increase consultant intensity, we should consider the much harder question on how to spend the same money to maximum effect. Consultant time is scarce and so should be tailored to the time, place and particular conditions where it price of propecia in canada is most beneficial over the week as a whole.
For some patients though, more rapid access to diagnostic tests or the increased use of skilled nurses during recovery may be much more critical to improving outcomes. Studies of the weekend effect drew attention to potentially price of propecia in canada dangerous levels of staffing that undoubtedly posed risks to patients. At this point, however, we need more precise studies that directly examine standards of care and the factors that influence the care delivered.
We can then define and target interventions price of propecia in canada effectively and make best use of scarce resources.Ethics statementsPatient consent for publicationNot required.The Harvard Medical Practice Study brought the issue of patient safety into the public eye and demonstrated that patients are often harmed by the care they receive.1 It used retrospective chart review to identify adverse events. Since its publication in 1991, considerable focus has been placed on trying to improve the methods for understanding the prevalence of harm in hospitals. These efforts have led to deeper price of propecia in canada understanding of the relative strengths and weaknesses of the tools we currently have for adverse event identification.
Still, most organisations do not have robust approaches for tracking all types of harm routinely. Other efforts have sought to assess safety not just in hospitals but across national health systems, and at one point in price of propecia in canada time, and to track and trend.Developing better approaches for measuring safety routinely is critical if we are to understand how many patients are being harmed, what the primary causes are and whether care is getting safer or less safe. However, it is also work that needs to be contextualised and the limitations of our tools must be appreciated.2 3The Irish National Adverse Event Study 2 (INAES-2) is presented in this issue.4 In this study, Connolly and colleagues used retrospective chart review to find adverse events at eight Irish hospitals in 2015 and compare these to previously reported price of propecia in canada data from 2009.
Retrospective chart review was the first method used in this space5 6 and is still a mainstay for national studies assessing rates of adverse events,7â12 although approaches using claims data are also used widely and are much less expensive though much less sensitive.13 The original approach using retrospective chart review relied on information exclusively gathered from retrospective review of randomly selected medical records, but it has since been bolstered by the creation of standardised triggers,14 and more rigorous methods for chart review which make it more sensitive for finding adverse events, and more reliable. Despite this, price of propecia in canada retrospective chart review has many limitations, most notably the level of agreement between abstractors and its reliance on the completeness of documentation in medical charts.15The issue of reliance on documentation is especially important. There have been well-conceived critiques that have raised concern related to underdocumentation of errors that occur in hospitals, as well as those that have raised concern that the findings from longitudinal studies looking at trends may be confounded by improved documentation resulting in an overestimation of the true (comparative) incidence of events.
These are both legitimate price of propecia in canada concerns. The INAES-2 study, as in prior similar work looking at multi-institution adverse event rates over time,16 17 showed an increase in events over time but no change in preventable harm. We are left not knowing if this represents a change in safety or a change in documentation.These concerns have led other investigators to develop adverse event identification approaches to enable more real-time identification, leveraging a broader set of data for the interpretation of the preventability and impact of these events.18 19 Prospective event identification, or the near real-time application of triggers, can also incorporate price of propecia in canada the perspectives of staff in the clinical environment around the time of the event to provide additional insights.
Even with this more comprehensive, contemporaneous collection of data however, agreement continues to be variable between reviewers.20â22Looking to spontaneous reporting from front-line staff, rather than retrospectively or prospectively monitoring for triggers, is another method that has been proposed as a mechanism for identifying the prevalence of adverse events over time. Similar to documentation, however, concerns exist about the under-reporting of events by front-line staff in safety reporting systems.23 24 Moreover, spontaneous reporting routinely underestimates the incidence of price of propecia in canada adverse events for some types of events by a factor of 20.25The inverse is also likely true that advances in safety culture may increase reporting, without any change in the frequency of actual events. Indeed, in the INAES-2 study, the researchers found that although safety reports increased threefold, adverse event rates did not change.
This highlights the challenge of using price of propecia in canada safety reports alone as a proxy for adverse events. Instead, the insights from safety reporting may hold promise for other uses in the safety space, such as providing a signal for the degree of staff engagement in safety, enabling the identification of near misses and facilitating the identification of significant events that require root cause analysis.Because of the variability that exists in the methods mentioned, many investigators have attempted to identify more reliable ways to identify adverse events. Several studies have employed reimbursement codes (in the USA, International Classification of Diseases Ninth Revision codes) as a mechanism to screen for adverse events.26â28 These systems, which aim to identify complications of medical care by looking for codes that are highly associated with adverse events, have largely been shown to be ineffective.29 30 price of propecia in canada This is likely to be multifactorial, with an inability to identify which conditions predated the current healthcare encounter, a lack of incentives to use coding to identify adverse events and their limited ability to accurately capture the full clinical picture all contributing to their limited efficacy.31Other approaches have leveraged information systems to screen for adverse events, which is almost certainly how this will be done in the future.32 This works better for some categories of events than for others.
Identification for some events is relatively straightforward, for example, for the development of acute kidney injury in which there is a biomarker to track (rise in creatinine), which routinely appears when the event is present. However, the price of propecia in canada identification of newly altered mental status, for example, is much more challenging. For events such as falls, which are almost always documented in electronic health record (EHR) systems, this also works well.
Commercial products that sift through data from the EHR are available price of propecia in canada to find adverse events for inpatients, while the situation regarding adverse event detection is much less advanced in the ambulatory setting, even though EHR use is widespread in developed countries. Among the main types of inpatient adverse events, hospital-acquired s, adverse drug events and falls can readily be detected in inpatients, while the situation is more complex for deep venous thromboses/pulmonary emboli, surgical injuries, specific types of pressure ulcers and missed diagnoses.32 Novel approaches that are highly effective for identifying wrong patient errors have been developed, such as âretract and reorderâ detection, which identifies these errors effectively.33 This has led to interventions such as showing the photograph of a patient to the ordering clinician, which reduced the likelihood of a wrong patient order by 43% in one study.34 Still, most organisations do not have a robust sense of how often their patients experience adverse events across the spectrum of care.The challenge of adverse event identification is multiplied by the importance of understanding one moment in time and, as the authors in the INAES-2 study aim to do, trying to look at trends. This will be essential as we continue to mobilise large efforts to improve safety and as these compete with other price of propecia in canada priorities.
As with all work in quality, having robust metrics is vital. In safety, however, we have in many ways been âflying blindââinitiating large-scale efforts to decrease the rate of adverse events without having reliable ways to measure their prevalence over time.It is important to emphasise that this lack of insight into performance is not equally distributed across all categories of adverse events.3 In fact, as proposed recently by Shojania price of propecia in canada and Marang-van de Mheen, the incidence of adverse events may be best understood as a composite measureâwith all of the limitations that come with looking at a measure with many composite parts.35 When broken apart, what we come to understand is that some of our mechanisms for identifying certain types of events are likely much more reliable than others. In the USA, for example, where the Agency for Healthcare Research and Quality has leveraged standardised methods for collecting and reporting national performance on a set of specific healthcare-associated s, we have much better insight into performance over time related to such healthcare-associated s than we do, for instance, with diagnostic error.Lastly, the challenge of interpreting national adverse event data over time is complicated by the nuances associated with the interfaces between politics and science.
In our personal experience, we have encountered challenges reporting results of safety studies that are tied to ministries of health.36 Related to the INAES-2 study specifically, Ireland has a long history of sensationalised media coverage of data pointing to opportunities for improved care, further complicating researchersâ ability to conduct this work free of price of propecia in canada influence.37Ultimately, the work presented by Connolly and colleagues is critically important work and we suggest that all health systems should be monitoring adverse event rates over time. The mechanisms for doing this, though, should rapidly evolve. With hospitals increasingly leveraging EHRs, data being collected in more uniform ways and advances in natural language processing and artificial intelligence, a future in which we have reliable measures of adverse events that are stable over time is likely within our reach price of propecia in canada.
To get from here to there, an ongoing investment in research with evaluation including leveraging artificial intelligence and natural language processing, and a commitment to transparent data reporting and enabling collaboration between organisations and governments focused on this work is essential.38 If we can achieve this, we could reasonably expect a future in which we have access to publicly available meaningful data on how many people are being harmed, and in what context, which could in turn transform safety.Ethics statementsPatient consent for publicationNot required..
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Long term effects of propecia
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