Buy cheap zithromax online

"Sexual dysfunction in younger buy cheap zithromax online men can result in depression and, in a subset of these men, suicidal ideation," Irwig said. Trinh said that these findings should not be over-interpreted to say that finasteride causes suicides, only that there seems to be an association. He thinks, however, that many more young men taking finasteride contemplate suicide than reported to VigiBase.

Abdulmaged Traish, a professor buy cheap zithromax online emeritus of urology at Boston University School of Medicine, believes that finasteride has a biological effect that disrupts the central nervous system in some young patients, which can have psychological effects like depression and suicide. The drug can help some people, he said. "But it comes with a high price, especially for a nonthreatening disorder like alopecia [hair loss]," he noted.

"It's not a disease that kills people." If a buy cheap zithromax online man wants to try finasteride for hair loss, he should at least be told of the risks, Traish said. "Physicians should have a frank, open discussion with the patient about the potential adverse side effects of the drug," he said. "If the patient still wants to take it, it's OK, but at least tell him, honestly, this is what we know." Traish also thinks that the U.S.

Food and Drug Administration should have a "boxed warning" that the drug may cause buy cheap zithromax online suicide ideation in some young men. No such warning is on the package insert now. The report was published online Nov.

11 in JAMA buy cheap zithromax online Dermatology. More information For more on depression in men, head to the National Institute of Mental Health. SOURCES.

Quoc-Dien Trinh, MD, division of urologic buy cheap zithromax online surgery, Brigham and Women's Hospital, Boston. Abdulmaged Traish, Ph.D., professor emeritus, urology, Boston University School of Medicine. Michael Irwig, MD, division of endocrinology, Beth Israel Deaconess Medical Center, Boston.

JAMA Dermatology, buy cheap zithromax online Nov. 11, 2020, onlineNov. 12, 2020 -- Global measles deaths increased 50% from 2016 to 2019, and more than 200,000 people died last year alone from the preventable disease.

The World Health Organization on Thursday released new statistics that show 869,770 cases of measles, one of the most contagious diseases known to science, around the world in buy cheap zithromax online 2019, the highest number since 1996. Increases were reported in all regions. The new report comes as officials in King County, WA, confirm a new case of measles in a child.

The boy was likely infected at buy cheap zithromax online Sea-Tac airport outside Seattle, the county public health department said Wednesday. €œMeasles outbreaks continue to circulate in many areas of the world. As long as people travel, no community is safe from measles introductions," says Jeff Duchin, MD, health officer for Public Health, Seattle and King County.

"Measles treatment buy cheap zithromax online is safe, effective, and offers excellent protection. If you aren't sure if you're up to date with the recommended doses of measles, mumps, and rubella treatment (MMR), see your health care provider and get a dose of MMR if needed. €œDuring our buy antibiotics zithromax, it’s important to stay up to date on all scheduled vaccinations for children, so we don’t lose important community protections against other serious s." Thus far in 2020, the CDC says there have been 12 confirmed cases in seven states or territories.

In the U.S., 1,282 measles buy cheap zithromax online cases were reported in 2019, almost four times as many as in 2018, according to the CDC. That was the highest annual number since 1992. Eighty-nine percent of those infected were unvaccinated or had an unknown vaccination status, and 10% were hospitalized, the agency says.

While cases of measles around the world dropped from 2010 to 2016, the numbers began moving in the wrong direction in 2017, the World Health Organization buy cheap zithromax online (WHO) says. One reason. Vaccination rates have stagnated for the past decade.

Measles vaccinations come in two buy cheap zithromax online doses. Global vaccination rates for the first dose is about 84% to 85%, the WHO says, while rates for the second dose are only 71%. Those rates need to be in the 95% range to control and prevent outbreaks.

Vaccination rates fell for U.S buy cheap zithromax online. Children in the first half of 2020, the CDC said in May, in part because of the antibiotics zithromax, which made some parents hesitant to visit doctor’s offices. Recommended vaccinations for 5-month-old children dropped from about two-thirds of kids from 2016 through 2019 to fewer than half in May of 2020, CNBC reported.

One bit of good news is that 2020 rates of are thus far buy cheap zithromax online lower, but the buy antibiotics zithromax has slowed vaccination efforts in many countries.CDC. "Influenza (Flu)," "Symptoms of antibiotics," "Flu Symptoms &. Complications." Pauline Yi, MD, internist and pediatrician, UCLA Health, Beverly Hills.

PLOS buy cheap zithromax online One. "Forecasting type-specific seasonal influenza after 26 weeks in the United States using influenza activities in other countries." Edward Belongia, MD, director, Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, WI. Alexandra Brown, spokesperson, Walgreen Co.

Christopher Savarese, spokesperson, Rite Aid buy cheap zithromax online Corp. Matthew Blanchette, spokesperson, CVS Pharmacy. Randy Bergen, MD, clinical lead, flu treatment program, Kaiser Permanente of Northern California.

WebMD. "buy antibiotics Prevention Might Translate to Record Low Flu Rates."SOURCES. Nada Hindiyeh, MD, clinical assistant professor of neurology specializing in headache medicine, Stanford University.

Urvish K. Patel, MD, research associate, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City. Cedric X.

Bryant, PhD, president and chief science officer, American Council on Exercise, San Diego, CA. Mayo Clinic. €œAerobic exercise.

Top 10 reasons to get physical,” “Exercise and stress. Get moving to manage stress,” “Migraine,” “Dehydration,” “Exercise headaches.” SleepFoundation.org. €œHow Exercise Impacts Sleep Quality.” Cleveland Clinic.

€œMigraine Headaches,” “Carbohydrates.” CDC. €œBenefits of Physical Activity.” American Migraine Foundation. €œTop 10 Migraine Triggers and How to Deal with Them.” Kaiser Permanente.

€œ10 warning signs of dehydration. And staying hydrated while wearing a mask.” American Diabetes Association. €œBlood Sugar and Exercise.” The Migraine Trust.

€œHypoglycaemia.” National Health Service (U.K.). €œCauses -- Migraine.” Eat Right. €œTiming Your Pre- and Post-Workout Nutrition,” “Exercise Safely in Hot Weather.” Migraine Canada.

€œCan travelling to a higher altitude trigger migraine attacks?. € The Journal of Headache Pain. €œThe association between migraine and physical exercise.”At issue is a complex legal concept known as “severability” -- that is, whether a specific provision can be “severed” from a larger law, without overturning the entire thing.

In two recent rulings, Miller notes, the Supreme Court has tended to narrowly focus on “severable” provisions without overturning entire laws, which the court regards primarily as the role of Congress. So, what is the Supreme Court likely to do with this case?. Health policy experts and legal scholars -- including Keith, Miller, and Musumeci -- suggest four likely scenarios.

The court could simply reject the suit, ruling that the plaintiffs have no standing to sue, preserving the status quo. €œThey could say, ‘Get out of court you’re not injured, so you have no reason to be here suing in the first place’ -- essentially saying this lawsuit should never have been allowed to move forward in the first place,” Keith says. No.

2. Kill the individual mandate but keep the Affordable Care Act. The justices could rule the individual mandate is unconstitutional, but it doesn’t mean the rest of Obamacare should be struck down.

No. 3. Kill the mandate and tweak some parts of Obamacare.

The court could also decide the individual mandate is unconstitutional and that some, but not all, parts of the law that it is designed to fund -- such as protections for people with preexisting conditions -- might also be in question. But experts say they don’t expect the justices to go this way. €œYou could, in theory, have an outcome where the individual mandate and the preexisting conditions fall and the rest of the law survives,” Musumeci says.

€œBut Roberts and Kavanaugh clearly said they don’t think the 2017 Congress intended to get rid of the preexisting conditions protections. So this tells me they are going to look at the issue in the most narrow way.” Keith agreed. €œFrom the hearing, that possibility seems a lot less likely than it even was before.

I was a lot more concerned about that possibility before the oral arguments.” No. 4. Overturn all of Obamacare.

Zithromax hearing loss

	Zithromax	Vibramycin
Buy with mastercard	20h	24h
Price per pill	Pharmacy	At walmart
Can you overdose	Yes	Yes
Pack price	Online	No
Can you get a sample	55	46

BOULDER, Mont zithromax hearing loss. €” Twice a year, Brian Tichenor makes the 1,200-mile drive each way from his home in Kansas to a defunct uranium mine in Montana, where he takes an elevator 85 feet below the surface to sit amid radioactive radon gas to ease the pain from his chronic eye condition. “I found it like I think a lot of people do,” zithromax hearing loss said Tichenor, 67. €œIt’s a point of desperation with conventional treatment.” While radon is commonly known as a hazardous gas removed from basements, people in pain travel to Montana and pay to breathe, drink and bathe in its radioactive particles.

The travelers view the radon exposure as low-dose radiation therapy for a long list of health issues. But the Environmental Protection Agency and the World Health Organization, among others, blame the gas as the second-leading zithromax hearing loss cause of lung cancer. Although cancer doctors use radiation as a front-line treatment to destroy dangerous cells, its role in the U.S. In low doses zithromax hearing loss for other ailments is disputed.

The zithromax has recharged that debate as clinical trials across the world test whether low doses of radiation can help treat buy antibiotics patients. But radon gas isn’t the same radiation U.S. Doctors use, zithromax hearing loss radiation experts caution. Radon is just one of the radioactive chemical elements and, because it’s a gas, it can be inhaled, making it particularly dangerous.

Sitting in a zithromax hearing loss radon-filled room and targeted radiation treatment in a medical facility are as different as “chalk and cheese,” said Brian Marples, a professor of radiation oncology at the University of Rochester. €œIn clinical therapy, we know exactly what the dose is, we know exactly where it’s going,” he said. Marples said much of the argument for radon’s therapeutic use relies on historical reports, unlike evidence-based research on clinical radiation. Still, some radiation experts are zithromax hearing loss split on what level of radon should be deemed dangerous and whether it could have positive health effects.

Another concern. The radon treatment in the mines is largely unregulated. The Montana Department of Public Health and Human Services doesn’t have the authority to permit zithromax hearing loss or license the mines, though department spokesperson Jon Ebelt said the adverse health risk from exposure is well known. The EPA also doesn’t have the power to mandate limits on radon.

EMAIL SIGN-Up Subscribe to California Healthline's free Daily Edition. Nonetheless, each year travelers head to zithromax hearing loss western Montana, where four inactive mines flush with radon are within 11 miles of one another near the rural communities of Basin and Boulder. Day passes range from $7 to $15. The gas naturally forms when radioactive elements in the mountains’ bedrock decay. Outside the Merry Widow Health Mine, a billboard-like banner announces “Fountain of zithromax hearing loss Youth.

FEEL YOUNG AGAIN!. € Inside zithromax hearing loss its tunnels, water seeps from the rock walls. Those who want full immersion can slip into a clawfoot tub filled with radon-tainted water. People soak their feet and hands in water or simply sit and work on a puzzle.

On a bench sits a zithromax hearing loss printout of a Forbes article on clinical trials that show low-dose radiation could be a treatment for buy antibiotics. To owner Chang Kim, 69, his business is a mission, especially for those with chronic medical conditions such as arthritis or diabetes. Those who swear by radon therapy say that, in low doses, a little stress on the body triggers the immune system to readapt and reduces inflammation. €œThe people coming zithromax hearing loss to the mines, they’re not stupid,” Kim said.

€œPeople’s lives are made better by them.” He learned about the mines 14 years ago when he and his wife, Veronica Kim, lived in Seattle and a connective tissue disease crumpled Veronica’s hands and feet. Traditional medicine wasn’t working zithromax hearing loss. After two sessions a year in the mines ever since, Veronica smiles when she shows her hands. €œThey’re not deformed anymore,” she said, adding she’s been able to cut down on her use of meloxicam, a medication to reduce pain and swelling.

Tichenor said zithromax hearing loss going to a mine with radon over six years has been one of the few things to calm his scleritis, a disorder that causes pain he describes as ice picks stabbing his eyes. As for its potential danger, he said radon treatment is just like any medication. Too much zithromax hearing loss can cause harm. He and other radon users point to European countries such as Germany, where the therapy may be controversial but doctors still can prescribe radon treatments for various conditions that insurance may even cover.

Free Enterprise Radon Health Mine, just outside Boulder in western Montana, is the state’s oldest mine that offers exposure to radioactive radon gas as a therapeutic treatment. Other forms of radiation treatment, under the supervision of doctors, are zithromax hearing loss getting renewed attention from researchers, but they caution such defunct mines offer unregulated radiation far different from what doctors would provide. (Katheryn Houghton/KHN) In the U.S., the EPA maintains that no level of radon exposure is risk-free even though everyone encounters the element in their lives. The agency notes radon is responsible for about 21,000 lung cancer deaths every year.

It recommends zithromax hearing loss that homeowners with radon levels of 4 picocuries per liter or more should add a radon-reduction system. By contrast, the owners of Montana’s oldest radon therapy mine, Free Enterprise Radon Health Mine, said their mine averages around 1,700. Monique Mandali said the federal guidelines are “a bunch of baloney.” Mandali lives in Helena, about 40 minutes from the mines, and tries to fit in three sessions at Free Enterprise a year — 25 hours of exposure spread out over 10 days for arthritis zithromax hearing loss in her back. €œPeople say, ‘Well, you know, but you could get lung cancer.’ And I respond, ‘I’m 74.

Who cares at this point?. €™â€ she zithromax hearing loss said. €œI’d rather take my chances with radon in terms of living with arthritis than with other Western medication.” Antone Brooks, formerly a U.S. Department of Energy scientist who studied low-dose radiation, is among those who zithromax hearing loss believe the federal government’s no-level-of-radon-exposure stance goes too far.

He pointed to research that indicates low doses of radiation potentially turn on pathways within bodies that could be protective. Though what’s considered a “low dose” depends on who’s talking. €œIf you want to go into a radon mine twice a year, I’d say, OK, zithromax hearing loss that’s not too much,” he said. €œIf you want to live down there, I’d say that’s too much.” In the early 1900s, before antibiotics were popularized, small doses of radiation were used to treat pneumonia with reports it relieved respiratory symptoms.

Since then, fear has largely kept the therapeutic potential of low-dose radiation untapped, said Dr. Mohammad Khan, an associate professor with the Winship Cancer zithromax hearing loss Institute at Emory University. But amid the zithromax, health care providers struggling to find treatments as hospital patients lie dying have been giving clinical radiation another look. So far, zithromax hearing loss the trials Khan has led show that patients who received targeted low-dose radiation to their lungs got off oxygen and out of the hospital sooner than those without the treatment.

Khan said more research is necessary, but it could eventually expand clinical radiation’s role for other illnesses. €œSome people think all radiation is the same thing, that all radiation is like the Hiroshima, Nagasaki bombs, but that’s clearly not the case,” Khan said. €œIf you put radiation in the hands of the experts and the right people — we use it wisely, we zithromax hearing loss use it carefully — that balances risk and benefits.” Merry Widow Health Mine is in a narrow canyon in Basin, Montana, where people pay to breathe, drink and soak in the old mine’s radioactive radon. (Katheryn Houghton/KHN) Inside the defunct Merry Widow Health Mine in Basin, Montana, water seeps from the rock walls.

People who want full immersion in its radon-laced waters can slip into this clawfoot tub as part of unregulated zithromax hearing loss radiation therapy touted by the mine’s owners but deemed potentially dangerous by some radiation experts. (Katheryn Houghton/KHN) The logo for Free Enterprise Radon Health Mine is a miner skipping with crutches in the air. Roughly 70 years ago, a woman said her bursitis disappeared after visiting the mine several times. Thousands of others followed suit zithromax hearing loss.

€œWe believe in it,” said Leah Lewis, who co-owns the mine with her husband, Ryan Lewis, and has relied on it to help treat her Crohn’s disease. The couple live on-site and grew up in Boulder, going into the tunnels just as their 5-year-old daughter does now. Her husband’s great-grandfather owned the mine, and the business has been in the family ever since zithromax hearing loss. €œNot one person has come back and said they’ve gotten lung cancer here,” Ryan Lewis said.

€œIf they did, they would shut us down so fast.” Aside from a billboard outside zithromax hearing loss Helena, the family doesn’t really advertise the business. Clients tend to find them. Like many companies, Ryan Lewis said, Free Enterprise took a hit last year as people canceled plans because of the zithromax. Before that, he said, the business broke about even, adding that radon can be “a hard sell.” But he said the family of cattle ranchers plans to keep it running as long as it doesn’t cost them zithromax hearing loss money.

€œThe land is an investment, and we want to keep it in the family,” he said. €œAnd there are zithromax hearing loss a lot of people who use this, and there’s some responsibility there.” This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Katheryn Houghton zithromax hearing loss. khoughton@kff.org, @K_Hought Related Topics Contact Us Submit a Story TipThree years ago, pharma giant Pfizer paid $24 million to settle federal allegations that it was paying kickbacks and inflating sales by reimbursing Medicare patients for out-of-pocket medication costs. By making prohibitively expensive medicine essentially zithromax hearing loss free for patients, the company induced them to use Pfizer drugs even as the price of one of those medicines, covered by Medicare and Medicaid, soared 44% to $225,000 a year, the Justice Department alleged. Now Pfizer is suing Uncle Sam to legalize essentially the same practice it was accused of three years ago — a fighting response to a federal crackdown that has resulted in a dozen drug companies being accused of similar practices.

A Pfizer win could cost taxpayers billions of dollars and erase an important control on pharma marketing after decades of regulatory erosion and soaring drug prices, say health policy analysts. A federal judge’s zithromax hearing loss ruling is expected any day. €œIf this is legal for Pfizer, Pfizer will not be the only pharmaceutical company to use this, and there will effectively be a gold rush,” government lawyer Jacob Lillywhite said in oral arguments last month. Pfizer’s legal argument “is aggressive,” said Chris Robertson, a professor of health law at Boston University.

€œBut I zithromax hearing loss think they’ve got such a political tailwind behind them” because of pocketbook pain over prescription medicine — even though it’s caused by pharma manufacturers. Pfizer’s message, “‘We’re just trying to help people afford their drugs,’ is pretty attractive,” he said. That’s not all that’s zithromax hearing loss working in Pfizer’s favor. Courts and regulations have been moving pharma’s way since the Food and Drug Administration allowed limited TV drug ads in the 1980s.

Other companies of all kinds also have gained free speech rights allowing aggressive marketing and political influence that would have been unthinkable decades ago, legal scholars say. Among other court arguments, Pfizer initially claimed that current zithromax hearing loss regulation violates its speech protections under the First Amendment, essentially saying it should be allowed to communicate freely with third-party charities to direct patient assistance. €œIt’s infuriating to realize that, as outlandish as they seem, these types of claims are finding a good deal of traction before many courts,” said Michelle Mello, a professor of law and medicine at Stanford University. €œDrug companies are surely aware zithromax hearing loss that the judicial trend has been toward more expansive recognition of commercial speech rights.” Pfizer’s lawsuit, in the Southern District of New York, seeks a judge’s permission to directly reimburse patient expenses for two of its heart-failure drugs each costing $225,000 a year.

An outside administrator would use Pfizer contributions to cover Medicare copays, deductibles and coinsurance for those drugs, which otherwise would cost patients about $13,000 a year. Letting pharma companies put money directly into patients’ pockets to pay for their own expensive medicines “does induce people to get a specific product” instead of shopping for a cheaper or more effective alternative, said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University. €œIt’s kind of the definition of a kickback.” Government rule-makers have warned against such payments since the launch of Medicare’s Part D drug benefit in zithromax hearing loss 2006. Drug companies routinely help privately insured patients with cost sharing through coupons and other means, but private carriers can negotiate the overall price.

Because Congress gave Medicare no control over prescription drug prices, having patients share at least part of the cost is the only economic force guarding against unlimited price hikes and industry profits at taxpayer expense. At the same zithromax hearing loss time, however, regulators have allowed the industry to help patients with copays by routing money through outside charities — but only as long as the charities are “bona fide, independent” organizations that don’t match drugmaker money with specific drugs. Several charities have blatantly violated that rule in recent years by colluding with pharma companies to subsidize particular drugs, the Justice Department has alleged. A dozen companies have paid more than zithromax hearing loss $1 billion to settle allegations of kickback violations.

Pfizer set up an internal fund at one of the charities, the Patient Access Network Foundation, to cover patient costs for a heart arrhythmia drug at exactly the same time it was raising the wholesale cost from $220 to $317 for a package of 40 capsules, the Justice Department said. Pfizer referred Medicare patients who needed the drug to the PAN Foundation, the government said. Under such arrangements, every $1 million channeled through a charity “has the potential to generate up zithromax hearing loss to $21 m[illion] for the sponsor company, funded by the U.S. Government,” Andrew Baum, a Citi pharma stock analyst, wrote in 2017.

Pfizer settled the case, saying it was not an admission of wrongdoing but resulted from its “desire to put this legal matter behind us.” The PAN Foundation and three other charities also made zithromax hearing loss deals to resolve allegations that they functioned as disallowed conduits for patient assistance for multiple pharma companies. One organization, the Virginia-based Caring Voice Coalition, shut down after government scrutiny. PAN’s settlement did not mention the alleged Pfizer transactions. Those were described in the separate government deal zithromax hearing loss with Pfizer.

The 2019 PAN agreement related to “legacy matters” and “did not involve any of PAN’s current operations or disease funds,” organization CEO Dan Klein said via a spokesperson. €œNonprofit patient assistance programs like PAN are necessary to help people access the critical medications they need to stay healthy.” But legal troubles have hardly slowed the pharma-funded patient assistance business. Four penalized nonprofits agreed to stop directing money to specific drugs, but they zithromax hearing loss continue to accept hundreds of millions of dollars in pharma donations to indirectly cover copays and other patient drug costs, organization reports and IRS filings show. HHS regulators allow the practice because the drug companies are not involved in deciding which patients and which drugs are subsidized.

Donations to six pharma-funded patient assistance charities reached $1.8 billion in 2019, only slightly less than the year before, a KHN analysis of their IRS filings zithromax hearing loss shows. That was nearly 50% higher than the amount from five years previously, before the Justice Department started cracking down. Last year Pfizer donated $39.7 million to PAN and five other charities helping patients with out-of-pocket drug costs, company disclosures show. If Pfizer’s lawsuit seeking to earmark such donations for its tafamidis heart-failure drugs opens the way for similar practices industrywide, it would drive up Medicare costs through rising prices and numbers of prescriptions, said Gerard Anderson, an economist and health policy professor at Johns Hopkins University’s zithromax hearing loss Bloomberg School of Public Health.

Such a program for tafamidis alone would increase Medicare costs by $30 billion, the Health and Human Services Department’s inspector general estimated. Pharma companies can “learn which patients zithromax hearing loss are using the drug, and they can market [and offer financial assistance] directly to that patient,” Anderson said. €œYou get a huge return.” Pfizer argues that its proposal, which the HHS inspector general called “highly suspect” in an advisory opinion before the company filed its lawsuit, is legal and sensible. €œProviding copay assistance to middle-income patients who have been prescribed tafamidis is an efficient and equitable way to lower their out-of-pocket costs,” company spokesperson Steven Danehy said.

But the real affordability problem for patients is that zithromax hearing loss tafamidis is too expensive, federal attorney Lillywhite said in court arguments last month. (HHS’ Office of Inspector General declined to comment.) Pfizer has “priced itself out of the market,” he said. The company is seeking to “do something that’s unprecedented, to upend decades of settled law and agency guidance” to boost sales of “what is the most expensive cardiovascular drug ever launched in the United States.” After the oral arguments, Pfizer dropped claims that HHS rules violate its free speech rights. Judge Mary Kay Vyskocil is considering only the company’s contention that a dedicated fund for tafamidis would not violate kickback prohibitions because, among other arguments, it is the doctor who decides to prescribe the drug and create revenue for Pfizer, zithromax hearing loss not the patient getting the financial assistance.

But legal analysts still see the case as part of a broad movement toward deregulation and corporate rights. A 1970s Supreme Court case, viewed as paving the way for an explosion of drug, lawyer and liquor ads as zithromax hearing loss well as corporate campaign donations, was about speech rights for prescription drug sellers in Virginia. In 2011 the court found that the First Amendment allows data miners to buy and sell prescription records from pharmacies, provided the patients aren’t identified. A year later, a federal appeals court cited speech protections when it overturned the conviction of a pharma sales rep who had been promoting a drug for uses not approved by the FDA.

Even if Pfizer loses its case, the climate may be ripe for similar challenges by other drugmakers, especially after the appointment of more than 200 federal judges by business-friendly President Donald Trump, legal scholars said. The federal kickback law doesn’t mention copay assistance charities “and wasn’t designed with these programs in mind,” said Mello, of Stanford. Pfizer’s lawsuit “should be a loud, clanging call to Congress” to explicitly define drug assistance subsidies as illegal kickbacks, she said. This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues.

Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation. Jay Hancock. jhancock@kff.org, @jayhancock1 Related Topics Contact Us Submit a Story Tip.

BOULDER, Mont buy cheap zithromax online cheap zithromax online canada. €” Twice a year, Brian Tichenor makes the 1,200-mile drive each way from his home in Kansas to a defunct uranium mine in Montana, where he takes an elevator 85 feet below the surface to sit amid radioactive radon gas to ease the pain from his chronic eye condition. “I found it like I buy cheap zithromax online think a lot of people do,” said Tichenor, 67. €œIt’s a point of desperation with conventional treatment.” While radon is commonly known as a hazardous gas removed from basements, people in pain travel to Montana and pay to breathe, drink and bathe in its radioactive particles.

The travelers view the radon exposure as low-dose radiation therapy for a long list of health issues. But the Environmental buy cheap zithromax online Protection Agency and the World Health Organization, among others, blame the gas as the second-leading cause of lung cancer. Although cancer doctors use radiation as a front-line treatment to destroy dangerous cells, its role in the U.S. In low buy cheap zithromax online doses for other ailments is disputed.

The zithromax has recharged that debate as clinical trials across the world test whether low doses of radiation can help treat buy antibiotics patients. But radon gas isn’t the same radiation U.S. Doctors use, radiation experts buy cheap zithromax online caution. Radon is just one of the radioactive chemical elements and, because it’s a gas, it can be inhaled, making it particularly dangerous.

Sitting in a radon-filled room and targeted radiation treatment in a medical buy cheap zithromax online facility are as different as “chalk and cheese,” said Brian Marples, a professor of radiation oncology at the University of Rochester. €œIn clinical therapy, we know exactly what the dose is, we know exactly where it’s going,” he said. Marples said much of the argument for radon’s therapeutic use relies on historical reports, unlike evidence-based research on clinical radiation. Still, some radiation experts are split on what level buy cheap zithromax online of radon should be deemed dangerous and whether it could have positive health effects.

Another concern. The radon treatment in the mines is largely unregulated. The Montana Department of Public Health and Human Services doesn’t have the authority to permit or license the mines, though department spokesperson Jon Ebelt said the adverse health risk buy cheap zithromax online from exposure is well known. The EPA also doesn’t have the power to mandate limits on radon.

EMAIL SIGN-Up Subscribe to California Healthline's free Daily Edition. Nonetheless, each year travelers head to western Montana, where four inactive mines buy cheap zithromax online flush with radon are within 11 miles of one another near the rural communities of Basin and Boulder. Day passes range from $7 to $15. The gas naturally forms when radioactive elements in the mountains’ bedrock decay. Outside the buy cheap zithromax online Merry Widow Health Mine, a billboard-like banner announces “Fountain of Youth.

FEEL YOUNG AGAIN!. € Inside its tunnels, water seeps from the buy cheap zithromax online rock walls. Those who want full immersion can slip into a clawfoot tub filled with radon-tainted water. People soak their feet and hands in water or simply sit and work on a puzzle.

On a bench sits a printout of a Forbes article on buy cheap zithromax online clinical trials that show low-dose radiation could be a treatment for buy antibiotics. To owner Chang Kim, 69, his business is a mission, especially for those with chronic medical conditions such as arthritis or diabetes. Those who swear by radon therapy say that, in low doses, a little stress on the body triggers the immune system to readapt and reduces inflammation. €œThe people coming buy cheap zithromax online to the mines, they’re not stupid,” Kim said.

€œPeople’s lives are made better by them.” He learned about the mines 14 years ago when he and his wife, Veronica Kim, lived in Seattle and a connective tissue disease crumpled Veronica’s hands and feet. Traditional medicine wasn’t working buy cheap zithromax online. After two sessions a year in the mines ever since, Veronica smiles when she shows her hands. €œThey’re not deformed anymore,” she said, adding she’s been able to cut down on her use of meloxicam, a medication to reduce pain and swelling.

Tichenor said going to a mine with radon over six years has been one of the few things to calm his scleritis, a disorder that causes buy cheap zithromax online pain he describes as ice picks stabbing his eyes. As for its potential danger, he said radon treatment is just like any medication. Too much can cause harm buy cheap zithromax online. He and other radon users point to European countries such as Germany, where the therapy may be controversial but doctors still can prescribe radon treatments for various conditions that insurance may even cover.

Free Enterprise Radon Health Mine, just outside Boulder in western Montana, is the state’s oldest mine that offers exposure to radioactive radon gas as a therapeutic treatment. Other forms of radiation treatment, under buy cheap zithromax online the supervision of doctors, are getting renewed attention from researchers, but they caution such defunct mines offer unregulated radiation far different from what doctors would provide. (Katheryn Houghton/KHN) In the U.S., the EPA maintains that no level of radon exposure is risk-free even though everyone encounters the element in their lives. The agency notes radon is responsible for about 21,000 lung cancer deaths every year.

It recommends that homeowners with radon levels of 4 picocuries per liter or more buy cheap zithromax online should add a radon-reduction system. By contrast, the owners of Montana’s oldest radon therapy mine, Free Enterprise Radon Health Mine, said their mine averages around 1,700. Monique Mandali said the federal guidelines are “a bunch of baloney.” Mandali lives in Helena, about 40 minutes from the mines, and tries to fit in three sessions at Free Enterprise a year — buy cheap zithromax online 25 hours of exposure spread out over 10 days for arthritis in her back. €œPeople say, ‘Well, you know, but you could get lung cancer.’ And I respond, ‘I’m 74.

Who cares at this point?. €™â€ she buy cheap zithromax online said. €œI’d rather take my chances with radon in terms of living with arthritis than with other Western medication.” Antone Brooks, formerly a U.S. Department of Energy buy cheap zithromax online scientist who studied low-dose radiation, is among those who believe the federal government’s no-level-of-radon-exposure stance goes too far.

He pointed to research that indicates low doses of radiation potentially turn on pathways within bodies that could be protective. Though what’s considered a “low dose” depends on who’s talking. €œIf you want to go into a radon mine twice a year, buy cheap zithromax online I’d say, OK, that’s not too much,” he said. €œIf you want to live down there, I’d say that’s too much.” In the early 1900s, before antibiotics were popularized, small doses of radiation were used to treat pneumonia with reports it relieved respiratory symptoms.

Since then, fear has largely kept the therapeutic potential of low-dose radiation untapped, said Dr. Mohammad Khan, an associate professor with the buy cheap zithromax online Winship Cancer Institute at Emory University. But amid the zithromax, health care providers struggling to find treatments as hospital patients lie dying have been giving clinical radiation another look. So far, the trials Khan has led show that buy cheap zithromax online patients who received targeted low-dose radiation to their lungs got off oxygen and out of the hospital sooner than those without the treatment.

Khan said more research is necessary, but it could eventually expand clinical radiation’s role for other illnesses. €œSome people think all radiation is the same thing, that all radiation is like the Hiroshima, Nagasaki bombs, but that’s clearly not the case,” Khan said. €œIf you put radiation in the hands of the experts and the right people — we use it wisely, we use it carefully — that balances risk and benefits.” Merry Widow Health Mine is in a narrow canyon in Basin, Montana, where people pay to breathe, drink and soak in the buy cheap zithromax online old mine’s radioactive radon. (Katheryn Houghton/KHN) Inside the defunct Merry Widow Health Mine in Basin, Montana, water seeps from the rock walls.

People who want full immersion in its radon-laced waters can slip buy cheap zithromax online into this clawfoot tub as part of unregulated radiation therapy touted by the mine’s owners but deemed potentially dangerous by some radiation experts. (Katheryn Houghton/KHN) The logo for Free Enterprise Radon Health Mine is a miner skipping with crutches in the air. Roughly 70 years ago, a woman said her bursitis disappeared after visiting the mine several times. Thousands of buy cheap zithromax online others followed suit.

€œWe believe in it,” said Leah Lewis, who co-owns the mine with her husband, Ryan Lewis, and has relied on it to help treat her Crohn’s disease. The couple live on-site and grew up in Boulder, going into the tunnels just as their 5-year-old daughter does now. Her husband’s great-grandfather owned the mine, and the business buy cheap zithromax online has been in see here now the family ever since. €œNot one person has come back and said they’ve gotten lung cancer here,” Ryan Lewis said.

€œIf they did, they would shut us down so fast.” Aside from a billboard outside Helena, the family doesn’t really advertise buy cheap zithromax online the business. Clients tend to find them. Like many companies, Ryan Lewis said, Free Enterprise took a hit last year as people canceled plans because of the zithromax. Before that, he said, the business broke about even, adding that buy cheap zithromax online radon can be “a hard sell.” But he said the family of cattle ranchers plans to keep it running as long as it doesn’t cost them money.

€œThe land is an investment, and we want to keep it in the family,” he said. €œAnd there are a lot of people who use this, and there’s some responsibility there.” This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth buy cheap zithromax online journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Katheryn buy cheap zithromax online Houghton. khoughton@kff.org, @K_Hought Related Topics Contact Us Submit a Story TipThree years ago, pharma giant Pfizer paid $24 million to settle federal allegations that it was paying kickbacks and inflating sales by reimbursing Medicare patients for out-of-pocket medication costs. By making prohibitively expensive medicine essentially free for patients, the company induced them to use Pfizer drugs even as the price of one of buy cheap zithromax online those medicines, covered by Medicare and Medicaid, soared 44% to $225,000 a year, the Justice Department alleged. Now Pfizer is suing Uncle Sam to legalize essentially the same practice it was accused of three years ago — a fighting response to a federal crackdown that has resulted in a dozen drug companies being accused of similar practices.

A Pfizer win could cost taxpayers billions of dollars and erase an important control on pharma marketing after decades of regulatory erosion and soaring drug prices, say health policy analysts. A federal buy cheap zithromax online judge’s ruling is expected any day. €œIf this is legal for Pfizer, Pfizer will not be the only pharmaceutical company to use this, and there will effectively be a gold rush,” government lawyer Jacob Lillywhite said in oral arguments last month. Pfizer’s legal argument “is aggressive,” said Chris Robertson, a professor of health law at Boston University.

€œBut I think they’ve got such a political tailwind behind them” because of pocketbook pain over prescription medicine — even though it’s caused by buy cheap zithromax online pharma manufacturers. Pfizer’s message, “‘We’re just trying to help people afford their drugs,’ is pretty attractive,” he said. That’s not all that’s working in Pfizer’s favor buy cheap zithromax online. Courts and regulations have been moving pharma’s way since the Food and Drug Administration allowed limited TV drug ads in the 1980s.

Other companies of all kinds also have gained free speech rights allowing aggressive marketing and political influence that would have been unthinkable decades ago, legal scholars say. Among other court buy cheap zithromax online arguments, Pfizer initially claimed that current regulation violates its speech protections under the First Amendment, essentially saying it should be allowed to communicate freely with third-party charities to direct patient assistance. €œIt’s infuriating to realize that, as outlandish as they seem, these types of claims are finding a good deal of traction before many courts,” said Michelle Mello, a professor of law and medicine at Stanford University. €œDrug companies are surely aware that the judicial trend has been toward more expansive recognition of commercial speech rights.” Pfizer’s lawsuit, in the buy cheap zithromax online Southern District of New York, seeks a judge’s permission to directly reimburse patient expenses for two of its heart-failure drugs each costing $225,000 a year.

An outside administrator would use Pfizer contributions to cover Medicare copays, deductibles and coinsurance for those drugs, which otherwise would cost patients about $13,000 a year. Letting pharma companies put money directly into patients’ pockets to pay for their own expensive medicines “does induce people to get a specific product” instead of shopping for a cheaper or more effective alternative, said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University. €œIt’s kind of the definition of a kickback.” Government rule-makers have warned against such payments since the launch of Medicare’s Part D drug benefit in buy cheap zithromax online 2006. Drug companies routinely help privately insured patients with cost sharing through coupons and other means, but private carriers can negotiate the overall price.

Because Congress gave Medicare no control over prescription drug prices, having patients share at least part of the cost is the only economic force guarding against unlimited price hikes and industry profits at taxpayer expense. At the same time, however, regulators have allowed the industry to help patients with copays by routing money through outside charities — but only as long as the charities are buy cheap zithromax online “bona fide, independent” organizations that don’t match drugmaker money with specific drugs. Several charities have blatantly violated that rule in recent years by colluding with pharma companies to subsidize particular drugs, the Justice Department has alleged. A dozen companies have paid more than $1 billion buy cheap zithromax online to settle allegations of kickback violations.

Pfizer set up an internal fund at one of the charities, the Patient Access Network Foundation, to cover patient costs for a heart arrhythmia drug at exactly the same time it was raising the wholesale cost from $220 to $317 for a package of 40 capsules, the Justice Department said. Pfizer referred Medicare patients who needed the drug to the PAN Foundation, the government said. Under such arrangements, every $1 million channeled through a charity “has the potential to generate up to $21 buy cheap zithromax online m[illion] for the sponsor company, funded by the U.S. Government,” Andrew Baum, a Citi pharma stock analyst, wrote in 2017.

Pfizer settled the case, saying it was not buy cheap zithromax online an admission of wrongdoing but resulted from its “desire to put this legal matter behind us.” The PAN Foundation and three other charities also made deals to resolve allegations that they functioned as disallowed conduits for patient assistance for multiple pharma companies. One organization, the Virginia-based Caring Voice Coalition, shut down after government scrutiny. PAN’s settlement did not mention the alleged Pfizer transactions. Those were described in the separate government deal buy cheap zithromax online with Pfizer.

The 2019 PAN agreement related to “legacy matters” and “did not involve any of PAN’s current operations or disease funds,” organization CEO Dan Klein said via a spokesperson. €œNonprofit patient assistance programs like PAN are necessary to help people access the critical medications they need to stay healthy.” But legal troubles have hardly slowed the pharma-funded patient assistance business. Four penalized nonprofits agreed to stop directing money to specific drugs, but they continue to accept hundreds of millions of dollars in pharma donations to indirectly buy cheap zithromax online cover copays and other patient drug costs, organization reports and IRS filings show. HHS regulators allow the practice because the drug companies are not involved in deciding which patients and which drugs are subsidized.

Donations to six pharma-funded patient assistance charities reached $1.8 billion in 2019, only slightly less than the year before, a KHN analysis of their buy cheap zithromax online IRS filings shows. That was nearly 50% higher than the amount from five years previously, before the Justice Department started cracking down. Last year Pfizer donated $39.7 million to PAN and five other charities helping patients with out-of-pocket drug costs, company disclosures show. If Pfizer’s lawsuit seeking to earmark such donations for its tafamidis heart-failure drugs opens the way for similar practices industrywide, it would drive up Medicare costs through rising prices and numbers buy cheap zithromax online of prescriptions, said Gerard Anderson, an economist and health policy professor at Johns Hopkins University’s Bloomberg School of Public Health.

Such a program for tafamidis alone would increase Medicare costs by $30 billion, the Health and Human Services Department’s inspector general estimated. Pharma companies can “learn which patients are using the drug, and they can market [and offer financial assistance] directly to buy cheap zithromax online that patient,” Anderson said. €œYou get a huge return.” Pfizer argues that its proposal, which the HHS inspector general called “highly suspect” in an advisory opinion before the company filed its lawsuit, is legal and sensible. €œProviding copay assistance to middle-income patients who have been prescribed tafamidis is an efficient and equitable way to lower their out-of-pocket costs,” company spokesperson Steven Danehy said.

But the real affordability problem for patients is that tafamidis is too expensive, buy cheap zithromax online federal attorney Lillywhite said in court arguments last month. (HHS’ Office of Inspector General declined to comment.) Pfizer has “priced itself out of the market,” he said. The company is seeking to “do something that’s unprecedented, to upend decades of settled law and agency guidance” to boost sales of “what is the most expensive cardiovascular drug ever launched in the United States.” After the oral arguments, Pfizer dropped claims that HHS rules violate its free speech rights. Judge Mary Kay Vyskocil is considering only the company’s contention that a dedicated fund for buy cheap zithromax online tafamidis would not violate kickback prohibitions because, among other arguments, it is the doctor who decides to prescribe the drug and create revenue for Pfizer, not the patient getting the financial assistance.

But legal analysts still see the case as part of a broad movement toward deregulation and corporate rights. A 1970s Supreme Court case, viewed as paving the way for buy cheap zithromax online an explosion of drug, lawyer and liquor ads as well as corporate campaign donations, was about speech rights for prescription drug sellers in Virginia. In 2011 the court found that the First Amendment allows data miners to buy and sell prescription records from pharmacies, provided the patients aren’t identified. A year later, a federal appeals court cited speech protections when it overturned the conviction of a pharma sales rep who had been promoting a drug for uses not approved by the FDA.

Even if Pfizer loses its case, the climate may be ripe for similar challenges by other drugmakers, especially after the appointment of more than 200 federal buy cheap zithromax online judges by business-friendly President Donald Trump, legal scholars said. The federal kickback law doesn’t mention copay assistance charities “and wasn’t designed with these programs in mind,” said Mello, of Stanford. Pfizer’s lawsuit “should be a loud, clanging call to Congress” to explicitly define drug assistance subsidies as illegal kickbacks, buy cheap zithromax online she said. This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues.

Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to buy cheap zithromax online the nation. Jay Hancock. jhancock@kff.org, @jayhancock1 Related Topics Contact Us Submit a Story Tip.

What should my health care professional know before I take Zithromax?

They need to know if you have any of these conditions:;

• kidney disease; liver disease
• pneumonia
• stomach problems (especially colitis)
• other chronic illness; an unusual or allergic reaction to azithromycin
• other macrolide antibiotics (such as erythromycin), foods, dyes, or preservatives
• pregnant or trying to get pregnant
• breast-feeding

How to get prescribed zithromax

How to cite this how to get prescribed zithromax article:Singh https://www.peak-inspiration.com/testimonial/capgemini-chelsea-slater/ OP. The need for routine psychiatric assessment of buy antibiotics survivors. Indian J Psychiatry 2020;62:457-8buy antibiotics zithromax is expected how to get prescribed zithromax to bring a Tsunami of mental health issues. Public health emergencies may affect the well-being, safety, and security of both individuals and communities, which lead to a range of emotional reactions, unhealthy behavior, and noncompliance, with public health directives (such as home confinement and vaccination) in people who contact the disease as well as in the general population.[1] Thus far, there has been an increased emphasis on psychosocial factors such as loneliness, effect of quarantine, uncertainty, vulnerability to buy antibiotics , economic factors, and career difficulties, which may lead to increased psychiatric morbidity.Time has now come to pay attention to the direct effect of the zithromax on brain and psychiatric adverse symptoms, resulting from the treatment provided.

Viral s are known to be associated with psychiatric disorders such as depression, bipolar disorder, obsessive–compulsive disorder how to get prescribed zithromax (OCD), or schizophrenia. There was an increased incidence of psychiatric disorders following the Influenza zithromax. Karl Menninger described 100 cases of influenza presenting with psychiatric sequelae, which could mainly be categorized as how to get prescribed zithromax dementia praecox, delirium, other psychoses, and unclassified subtypes. Dementia praecox constituted the largest number among all these cases.[2] Neuroinflammation is now known as the key factor in genesis and exacerbation of psychiatric disorders, particularly depression and bipolar disorders.Emerging evidence points toward the neurotropic properties of the antibiotics zithromax.

Loss of smell and taste as an initial symptom points toward early how to get prescribed zithromax involvement of olfactory bulb. The rapid spread to brain has been demonstrated through retrograde axonal transport.[3] The zithromax can enter the brain through endothelial cells lining the blood–brain barrier and also through other nerves such as the vagus nerve.[4] Cytokine storm, a serious immune reaction to the zithromax, can activate brain glial cells, leading to delirium, depression, bipolar disorder, and OCD.Studies examining psychiatric disorders in acute patients suffering from buy antibiotics found almost 40% of such patients suffering from anxiety, depression, and posttraumatic stress disorder.[5] The data on long-term psychiatric sequelae in patients who have recovered from acute illness are limited. There are anecdotal reports of psychosis and mania occurring in patients of buy antibiotics following discharge from hospital. This may be either due to how to get prescribed zithromax the direct effect of the zithromax on the brain or due to the neuropsychiatric effects of drugs used to treat the or its complications.

For example, behavioral toxicity of high-dose corticosteroids which are frequently used during the treatment of severe cases to prevent and manage cytokine storm.The patients with buy antibiotics can present with many neuropsychiatric disorders, which may be caused by direct inflammation, central nervous system effects of cytokine storm, aberrant epigenetic modifications of stress-related genes, glial activation, or treatment emergent effects.[6] To assess and manage various neuropsychiatric complications of buy antibiotics, the psychiatric community at large should equip itself with appropriate assessment tools and management guidelines to effectively tackle this unprecedented wave of psychiatric ailments. References how to get prescribed zithromax 1.Pfefferbaum B, North CS. Mental health and the buy antibiotics zithromax. N Engl how to get prescribed zithromax J Med 2020;383:510-2.

2.Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of unknown how to get prescribed zithromax etiology in Wuhan, China. The mystery and the miracle. J Med Virol 2020;92:401-2.

3.Fodoulian L, Tuberosa J, Rossier D, Landis BN, Carleton how to get prescribed zithromax A, Rodriguez I. antibiotics receptor and entry genes are expressed by sustentacular cells in the human olfactory neuroepithelium. BioRxiv 2020.03.31.013268 how to get prescribed zithromax. Doi.

Https://doi.org/10.1101/2020.03.31.013268. 4.Lochhead JJ, Thorne RG. Intranasal delivery of biologics to the central nervous system. Adv Drug Deliv Rev 2012;64:614-28.

5.Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe antibiotics s. A systematic review and meta-analysis with comparison to the buy antibiotics zithromax. Lancet Psychiatry 2020;7:611-27.

6.Steardo L Jr., Steardo L, Verkhratsky A. Psychiatric face of buy antibiotics. Transl Psychiatry 2020;10:261. Correspondence Address:Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1169_2Abstract The buy antibiotics zithromax has emerged as a major stressor of a global scale, affecting all aspects of our lives, and is likely to contribute to a surge of mental ill health. Ancient Hindu scriptures, notably the Bhagavad Gita, have a wealth of insights that can help approaches to build psychological resilience for individuals at risk, those affected, as well as for caregivers.

The path of knowledge (Jnana yoga) promotes accurate awareness of nature of the self, and can help reframe our thinking from an “I” to a “we mode,” much needed for collectively mitigating the spread of the antibiotics. The path of action (Karma yoga) teaches the art of selfless action, providing caregivers and frontline health-care providers a framework to continue efforts in the face of uncertain consequences. Finally, the path of meditation (Raja yoga) offers a multipronged approach to healthy lifestyle and mindful meditation, which may improve resilience to the illness and its severe consequences. While more work is needed to empirically examine the potential value of each of these approaches in modern psychotherapy, the principles herein may already help individuals facing and providing care for the buy antibiotics zithromax.Keywords.

Bhagavad Gita, buy antibiotics, YogaHow to cite this article:Keshavan MS. Building resilience in the buy antibiotics era. Three paths in the Bhagavad Gita. Indian J Psychiatry 2020;62:459-61The buy antibiotics crisis has changed our world in just a matter of months, thrusting us into danger, uncertainty, fear, and of course social isolation.

At the time of this writing, over 11 million individuals have been affected worldwide (India is fourth among all countries, 674,515) and over half a million people have died. The buy antibiotics zithromax has been an unprecedented global stressor, not only because of the disease burden and mortality but also because of economic upheaval. The very fabric of the society is disrupted, affecting housing, personal relationships, travel, and all aspects of lifestyle. The overwhelmed health-care system is among the most major stressors, leading to a heightened sense of vulnerability.

No definitive treatments or treatment is on the horizon yet. Psychiatry has to brace up to an expected mental health crisis resulting from this global stressor, not only with regard to treating neuropsychiatric consequences but also with regard to developing preventive approaches and building resilience.Thankfully, there is a wealth of wisdom to help us in our ancient scriptures such as the Bhagavad Gita[1] for building psychological resilience. The Bhagavad Gita is a dialog between the Pandava prince Arjuna and his charioteer Krishna in the epic Mahabharata, the great tale of the Bharata Dynasty, authored by Sage Vyasa (c. 4–5 B.C.E.).

The dialog occurs in the 6th chapter of the epic and has over 700 verses. In this epic story, Arjuna, the righteous Pandava hero was faced with the dilemma of waging a war against his cousins, the Kauravas, for territory. Arjuna is confused and has no will to initiate the war. In this context, Krishna, his charioteer and spiritual mentor, counsels him.

The key principles of this spiritual discourse in the Gita are embodied in the broad concept of yoga, which literally means “Yog” or “to unite.” Applying three tenets of yoga can greatly help developing resilience at individual, group, and societal levels. A fourth path, Bhakti yoga, is a spiritual approach in the Gita which emphasizes loving devotion toward a higher power or principle, which may or may not involve a personal god. In this editorial, I focus on three paths that have considerable relevance to modern approaches to reliance-focused psychotherapy that may be especially relevant in the buy antibiotics era. Path of Knowledge The first concept in the Gita is the path of knowledge (Jnana Yoga, chapter 2).

The fundamental goal of Jnana yoga is to liberate oneself from the limited view of the individual ego, and to develop the awareness of one's self as part of a larger, universal self. Hindu philosophers were among the earliest to ask the question of “who am I” and concluded that the self is not what it seems. The self as we all know is a collection of our physical, mental, and social attributes that we create for ourselves with input from our perceptions, and input by our families and society. Such a world view leads to a tendency to crave for the “I” and for what is mine, and not consider the “We.” As Krishna in the Bhagavad Gita points out, the person who sees oneself in others, and others in oneself, really “sees.” Such awareness, which guides action in service of self as well as others, is critically important in our goals of collectively preventing the spread of the antibiotics.

A glaring example is the use of face masks, known to effectively slow the viral . Using the mask is as important to protecting oneself from the zithromax as well as protecting others from oneself. Nations such as the USA (and their leaders), who have given mixed messages to the public about the need to wear masks, have been showing a strikingly high number of cases as well as mortality. Unfortunately, such reluctance to wear masks (and thus model protective hygiene for the population), as in the case of the US leader, has stemmed from ego or vanity-related issues (i.e., how he would appear to other leaders!.

). This factor may at least partly underlie the worse buy antibiotics outcome in the USA. The simple lesson here is that it is important to first flatten the ego if one wants to flatten the zithromax curve!. Path of Action The second key concept is the path of action (Karma yoga, chapter 3).

Karma yoga is all about taking action without thinking, “what's in it for me.” As such, it seeks to mainly let go of one's ego. In the Bhagavad Gita, Arjuna is ambivalent about fighting because of the conflict regarding the outcome brought on by waging the war, i.e., having to kill some of his own kith and kin. Krishna reminds him that he should not hesitate, because it is his nature and duty (or Dharma), as a warrior, to protect the larger good, though it will have some downside consequences. The frontline health-care worker caring for severely ill patients with buy antibiotics is likely to have a similar emotional reaction as Arjuna, facing a lack of adequate treatments, high likelihood of mortality and of unpredictable negative outcomes, and risk to him/herself.

Compounding this, especially when resources such as ventilators are limited, the doctor may have to make tough decisions of whose life to save and whose not. Adding to this are personal emotions when facing with the death of patients, having to deliver bad news, and dealing with grieving relatives.[2] All these are likely to result in emotional anguish and guilt, leading to burnout and a war “neurosis.”So, what should the frontline health-care provider should do?. Krishna's counsel would be that the doctor should continue to perform his/her own dharma, but do so without desire or attachment, thereby performing action in the spirit of Karma best place to buy zithromax online yoga. Such action would be with detachment, without a desire for personal gain and being unperturbed by success or failure.

Such “Nishkaama Karma” (or selfless action) may help doctors working today in the buy antibiotics outbreak to carry forward their work with compassion, and accept the results of their actions with equanimity and without guilt. Krishna points out that training one's mind to engage in selfless action is not easy but requires practice (Abhyasa). Krishna is also emphatic about the need to protect oneself, in order to be able to effectively carry out one's duties. Path of Meditation The third core concept in the Gita is the path of meditation and self-reflection (Raja yoga, or Dhyana yoga, chapter 6).

It is considered the royal path (Raja means royal) for attaining self-realization, and often considered the 8-fold path of yoga (Ashtanga yoga) designed to discipline lifestyle, the body and mind toward realizing mindfulness and self-reflection. These techniques, which originated in India over two millennia ago, have evolved over recent decades and anticipate several approaches to contemplative psychotherapy, including dialectical behavior therapy, acceptance and commitment therapy, and mindfulness-based stress reduction.[3] These approaches are of particular relevance for stress reduction and resilience building in individuals faced by buy antibiotics-related emotional difficulties as well as health-care providers.[4]The majority of people affected by the buy antibiotics zithromax recover, but about 20% have severe disease, and the mortality is around 5%. Older individuals, those with obesity and comorbid medical illnesses such as diabetes and lung disease, are particularly prone to developing severe disease. It is possible that a state of chronic low-grade inflammation which underlies each of these conditions may increase the risk of disproportionate host immune reactions (with excessive release of cytokines), characterizing severe disease in those with buy antibiotics.[4] With this in mind, it is important to note that exercise, some forms of meditation, anti-inflammatory and antioxidant diet (such as turmeric and melatonin), and yoga have known benefits in reducing inflammation.[5],[6],[7],[8],[9] Sleep loss also elevates inflammatory cytokines.

Healthy sleep may reduce inflammation.[10] Clearly, a healthy lifestyle, including healthy sleep, exercise, and diet, may be protective against developing buy antibiotics-related severe complications. These principles of healthy living are beautifully summarized in the Bhagavad Gita.Yuktahara-viharasya yukta-cestasya karmasuYukta-svapnavabodhasya yogo bhavati duhkha-haHe who is temperate in his habits of eating, sleeping, working and recreation can mitigate all sorrows by practicing the yoga system.–Bhagavad Gita, Chapter 6, verse 17.The relevance of the Bhagavad Gita for modern psychotherapy has been widely reviewed.[11],[12] However, relatively little empirical literature exists on the effectiveness of versus spiritually integrated psychotherapy incorporating Hindu psychotherapeutic insights. Clearly, more work is needed, and buy antibiotics may provide an opportunity for conducting further empirical research.[13] In the meantime, using the principles outlined here may already be of benefit in helping those in need, and may be rapidly enabled in the emerging era of telehealth and digital health.[14]Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Pandurangi AK, Shenoy S, Keshavan MS.

Psychotherapy in the Bhagavad Gita, the Hindu scriptural text. Am J Psychiatry 2014;171:827-8. 2.Arango C. Lessons learned from the antibiotics health crisis in Madrid, Spain.

How buy antibiotics has changed our lives in the last 2 weeks [published online ahead of print, 2020 Apr 8]. Biol Psychiatry 2020;26:S0006-3223 (20) 31493-1. [doi. 10.1016/j.biopsych.

2020.04.003]. 3.Keshavan MS, Gangadhar GN, Hinduism PA. In. Spirituality and Mental Health Across Cultures, Evidence-Based Implications for Clinical Practice.

Oxford, England. Oxford University Press. In Press. 4.Habersaat KB, Betsch C, Danchin M, Sunstein CR, Böhm R, Falk A, et al.

Ten considerations for effectively managing the buy antibiotics transition. Nat Hum Behav 2020;4:677-87. Doi. 10.1038/s41562-020-0906-x.

Epub 2020 Jun 24. 5.Kumar K. Building resilience to buy antibiotics disease severity. J Med Res Pract 2020;9:1-7.

6.Bushell W, Castle R, Williams MA, Brouwer KC, Tanzi RE, Chopra D, et al. Meditation and Yoga practices as potential adjunctive treatment of antibiotics and buy antibiotics. A brief overview of key subjects [published online ahead of print, 2020 Jun 22]. J Altern Complement Med 2020;26:10.1089/acm.

7.Gupta H, Gupta M, Bhargava S. Potential use of turmeric in buy antibiotics [published online ahead of print, 2020 Jul 1]. Clin Exp Dermatol. 2020;10.1111/ced.14357.

Doi:10.1111/ced.14357. 8.Damiot A, Pinto AJ, Turner JE, Gualano B. Immunological implications of physical inactivity among older adults during the buy antibiotics zithromax [published online ahead of print, 2020 Jun 25]. Gerontology 2020:26;1-8.

[doi. 10.1159/000509216]. 9.El-Missiry MA, El-Missiry ZM, Othman AI. Melatonin is a potential adjuvant to improve clinical outcomes in individuals with obesity and diabetes with coexistence of buy antibiotics [published online ahead of print, 2020 Jun 29].

Eur J Pharmacol 2020;882:173329. 10.Mullington JM, Simpson NS, Meier-Ewert HK, Haack M. Sleep loss and inflammation. Best Pract Res Clin Endocrinol Metab 2010;24:775-84.

11.Balodhi JP, Keshavan MS. Bhagavad Gita and psychotherapy. Asian J Psychiatr 2011;4:300-2. 12.Bhatia SC, Madabushi J, Kolli V, Bhatia SK, Madaan V.

The Bhagavad Gita and contemporary psychotherapies. Indian J Psychiatry 2013;55:S315-21. 13.Keshavan MS. zithromaxs and psychiatry.

Repositioning research in context of buy antibiotics [published online ahead of print, 2020 May 7]. Asian J Psychiatr 2020;51:102159. [doi. 10.1016/j.ajp.

2020.102159]. 14.Torous J, Keshavan M. buy antibiotics, mobile health and serious mental illness. Schizophr Res 2020;218:36-7.

Correspondence Address:Matcheri S KeshavanRoom 542, Massachusetts Mental Health Center, 75 Fenwood Road, Boston, MA 02115 USASource of Support. None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_829_20.

How to cite this article:Singh buy cheap zithromax online Recommended Reading OP. The need for routine psychiatric assessment of buy antibiotics survivors. Indian J Psychiatry 2020;62:457-8buy antibiotics zithromax is expected to bring a Tsunami of mental buy cheap zithromax online health issues. Public health emergencies may affect the well-being, safety, and security of both individuals and communities, which lead to a range of emotional reactions, unhealthy behavior, and noncompliance, with public health directives (such as home confinement and vaccination) in people who contact the disease as well as in the general population.[1] Thus far, there has been an increased emphasis on psychosocial factors such as loneliness, effect of quarantine, uncertainty, vulnerability to buy antibiotics , economic factors, and career difficulties, which may lead to increased psychiatric morbidity.Time has now come to pay attention to the direct effect of the zithromax on brain and psychiatric adverse symptoms, resulting from the treatment provided. Viral s are known to be associated with psychiatric disorders such as depression, bipolar disorder, obsessive–compulsive disorder (OCD), or buy cheap zithromax online schizophrenia.

There was an increased incidence of psychiatric disorders following the Influenza zithromax. Karl Menninger described 100 cases of influenza presenting with psychiatric sequelae, buy cheap zithromax online which could mainly be categorized as dementia praecox, delirium, other psychoses, and unclassified subtypes. Dementia praecox constituted the largest number among all these cases.[2] Neuroinflammation is now known as the key factor in genesis and exacerbation of psychiatric disorders, particularly depression and bipolar disorders.Emerging evidence points toward the neurotropic properties of the antibiotics zithromax. Loss of smell and taste as an initial symptom points toward buy cheap zithromax online early involvement of olfactory bulb. The rapid spread to brain has been demonstrated through retrograde axonal transport.[3] The zithromax can enter the brain through endothelial cells lining the blood–brain barrier and also through other nerves such as the vagus nerve.[4] Cytokine storm, a serious immune reaction to the zithromax, can activate brain glial cells, leading to delirium, depression, bipolar disorder, and OCD.Studies examining psychiatric disorders in acute patients suffering from buy antibiotics found almost 40% of such patients suffering from anxiety, depression, and posttraumatic stress disorder.[5] The data on long-term psychiatric sequelae in patients who have recovered from acute illness are limited.

There are anecdotal reports of psychosis and mania occurring in patients of buy antibiotics following discharge from hospital. This may be either due to the direct buy cheap zithromax online effect of the zithromax on the brain or due to the neuropsychiatric effects of drugs used to treat the or its complications. For example, behavioral toxicity of high-dose corticosteroids which are frequently used during the treatment of severe cases to prevent and manage cytokine storm.The patients with buy antibiotics can present with many neuropsychiatric disorders, which may be caused by direct inflammation, central nervous system effects of cytokine storm, aberrant epigenetic modifications of stress-related genes, glial activation, or treatment emergent effects.[6] To assess and manage various neuropsychiatric complications of buy antibiotics, the psychiatric community at large should equip itself with appropriate assessment tools and management guidelines to effectively tackle this unprecedented wave of psychiatric ailments. References 1.Pfefferbaum B, North CS buy cheap zithromax online. Mental health and the buy antibiotics zithromax.

N Engl J buy cheap zithromax online Med 2020;383:510-2. 2.Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of buy cheap zithromax online unknown etiology in Wuhan, China. The mystery and the miracle. J Med Virol 2020;92:401-2.

3.Fodoulian L, Tuberosa J, buy cheap zithromax online Rossier D, Landis BN, Carleton A, Rodriguez I. antibiotics receptor and entry genes are expressed by sustentacular cells in the human olfactory neuroepithelium. BioRxiv 2020.03.31.013268 buy cheap zithromax online. Doi. Https://doi.org/10.1101/2020.03.31.013268.

4.Lochhead JJ, Thorne RG. Intranasal delivery of biologics to the central nervous system. Adv Drug Deliv Rev 2012;64:614-28. 5.Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, et al. Psychiatric and neuropsychiatric presentations associated with severe antibiotics s.

A systematic review and meta-analysis with comparison to the buy antibiotics zithromax. Lancet Psychiatry 2020;7:611-27. 6.Steardo L Jr., Steardo L, Verkhratsky A. Psychiatric face of buy antibiotics. Transl Psychiatry 2020;10:261.

Correspondence Address:Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1169_2Abstract The buy antibiotics zithromax has emerged as a major stressor of a global scale, affecting all aspects of our lives, and is likely to contribute to a surge of mental ill health. Ancient Hindu scriptures, notably the Bhagavad Gita, have a wealth of insights that can help approaches to build psychological resilience for individuals at risk, those affected, as well as for caregivers.

The path of knowledge (Jnana yoga) promotes accurate awareness of nature of the self, and can help reframe our thinking from an “I” to a “we mode,” much needed for collectively mitigating the spread of the antibiotics. The path of action (Karma yoga) teaches the art of selfless action, providing caregivers and frontline health-care providers a framework to continue efforts in the face of uncertain consequences. Finally, the path of meditation (Raja yoga) offers a multipronged approach to healthy lifestyle and mindful meditation, which may improve resilience to the illness and its severe consequences. While more work is needed to empirically examine the potential value of each of these approaches in modern psychotherapy, the principles herein may already help individuals facing and providing care for the buy antibiotics zithromax.Keywords. Bhagavad Gita, buy antibiotics, YogaHow to cite this article:Keshavan MS.

Building resilience in the buy antibiotics era. Three paths in the Bhagavad Gita. Indian J Psychiatry 2020;62:459-61The buy antibiotics crisis has changed our world in just a matter of months, thrusting us into danger, uncertainty, fear, and of course social isolation. At the time of this writing, over 11 million individuals have been affected worldwide (India is fourth among all countries, 674,515) and over half a million people have died. The buy antibiotics zithromax has been an unprecedented global stressor, not only because of the disease burden and mortality but also because of economic upheaval.

The very fabric of the society is disrupted, affecting housing, personal relationships, travel, and all aspects of lifestyle. The overwhelmed health-care system is among the most major stressors, leading to a heightened sense of vulnerability. No definitive treatments or treatment is on the horizon yet. Psychiatry has to brace up to an expected mental health crisis resulting from this global stressor, not only with regard to treating neuropsychiatric consequences but also with regard to developing preventive approaches and building resilience.Thankfully, there is a wealth of wisdom to help us in our ancient scriptures such as the Bhagavad Gita[1] for building psychological resilience. The Bhagavad Gita is a dialog between the Pandava prince Arjuna and his charioteer Krishna in the epic Mahabharata, the great tale of the Bharata Dynasty, authored by Sage Vyasa (c.

4–5 B.C.E.). The dialog occurs in the 6th chapter of the epic and has over 700 verses. In this epic story, Arjuna, the righteous Pandava hero was faced with the dilemma of waging a war against his cousins, the Kauravas, for territory. Arjuna is confused and has no will to initiate the war. In this context, Krishna, his charioteer and spiritual mentor, counsels him.

The key principles of this spiritual discourse in the Gita are embodied in the broad concept of yoga, which literally means “Yog” or “to unite.” Applying three tenets of yoga can greatly help developing resilience at individual, group, and societal levels. A fourth path, Bhakti yoga, is a spiritual approach in the Gita which emphasizes loving devotion toward a higher power or principle, which may or may not involve a personal god. In this editorial, I focus on three paths that have considerable relevance to modern approaches to reliance-focused psychotherapy that may be especially relevant in the buy antibiotics era. Path of Knowledge The first concept in the Gita is the path of knowledge (Jnana Yoga, chapter 2). The fundamental goal of Jnana yoga is to liberate oneself from the limited view of the individual ego, and to develop the awareness of one's self as part of a larger, universal self.

Hindu philosophers were among the earliest to ask the question of “who am I” and concluded that the self is not what it seems. The self as we all know is a collection of our physical, mental, and social attributes that we create for ourselves with input from our perceptions, and input by our families and society. Such a world view leads to a tendency to crave for the “I” and for what is mine, and not consider the “We.” As Krishna in the Bhagavad Gita points out, the person who sees oneself in others, and others in oneself, really “sees.” Such awareness, which guides action in service of self as well as others, is critically important in our goals of collectively preventing the spread of the antibiotics. A glaring example is the use of face masks, known to effectively slow the viral . Using the mask is as important to protecting oneself from the zithromax as well as protecting others from oneself.

Nations such as the USA (and their leaders), who have given mixed messages to the public about the need to wear masks, have been showing a strikingly high number of cases as well as mortality. Unfortunately, such reluctance to wear masks (and thus model protective hygiene for the population), as in the case of the US leader, has stemmed from ego or vanity-related issues (i.e., how he would appear to other leaders!. ). This factor may at least partly underlie the worse buy antibiotics outcome in the USA. The simple lesson here is that it is important to first flatten the ego if one wants to flatten the zithromax curve!.

Path of Action The second key concept is the path of action (Karma yoga, chapter 3). Karma yoga is all about taking action without thinking, “what's in it for me.” As such, it seeks to mainly let go of one's ego. In the Bhagavad Gita, Arjuna is ambivalent about fighting because of the conflict regarding the outcome brought on by waging the war, i.e., having to kill some of his own kith and kin. Krishna reminds him that he should not hesitate, because it is his nature and duty (or Dharma), as a warrior, to protect the larger good, though it will have some downside consequences. The frontline health-care worker caring for severely ill patients with buy antibiotics is likely to have a similar emotional reaction as Arjuna, facing a lack of adequate treatments, high likelihood of mortality and of unpredictable negative outcomes, and risk to him/herself.

Compounding this, especially when resources such as ventilators are limited, the doctor may have to make tough decisions of whose life to save and whose not. Adding to this are personal emotions when facing with the death of patients, having to deliver bad news, and dealing with grieving relatives.[2] All these are likely to result in emotional anguish and guilt, leading to burnout and a war “neurosis.”So, what should the frontline health-care provider should do?. Krishna's counsel would be that the doctor should continue to perform his/her own dharma, but do so without desire or attachment, thereby performing action in the spirit of Karma yoga. Such action would be with detachment, without a desire for personal gain and being unperturbed by success or failure. Such “Nishkaama Karma” (or selfless action) may help doctors working today in the buy antibiotics outbreak to carry forward their work with compassion, and accept the results of their actions with equanimity and without guilt.

Krishna points out that training one's mind to engage in selfless action is not easy but requires practice (Abhyasa). Krishna is also emphatic about the need to protect oneself, in order to be able to effectively carry out one's duties. Path of Meditation The third core concept in the Gita is the path of meditation and self-reflection (Raja yoga, or Dhyana yoga, chapter 6). It is considered the royal path (Raja means royal) for attaining self-realization, and often considered the 8-fold path of yoga (Ashtanga yoga) designed to discipline lifestyle, the body and mind toward realizing mindfulness and self-reflection. These techniques, which originated in India over two millennia ago, have evolved over recent decades and anticipate several approaches to contemplative psychotherapy, including dialectical behavior therapy, acceptance and commitment therapy, and mindfulness-based stress reduction.[3] These approaches are of particular relevance for stress reduction and resilience building in individuals faced by buy antibiotics-related emotional difficulties as well as health-care providers.[4]The majority of people affected by the buy antibiotics zithromax recover, but about 20% have severe disease, and the mortality is around 5%.

Older individuals, those with obesity and comorbid medical illnesses such as diabetes and lung disease, are particularly prone to developing severe disease. It is possible that a state of chronic low-grade inflammation which underlies each of these conditions may increase the risk of disproportionate host immune reactions (with excessive release of cytokines), characterizing severe disease in those with buy antibiotics.[4] With this in mind, it is important to note that exercise, some forms of meditation, anti-inflammatory and antioxidant diet (such as turmeric and melatonin), and yoga have known benefits in reducing inflammation.[5],[6],[7],[8],[9] Sleep loss also elevates inflammatory cytokines. Healthy sleep may reduce inflammation.[10] Clearly, a healthy lifestyle, including healthy sleep, exercise, and diet, may be protective against developing buy antibiotics-related severe complications. These principles of healthy living are beautifully summarized in the Bhagavad Gita.Yuktahara-viharasya yukta-cestasya karmasuYukta-svapnavabodhasya yogo bhavati duhkha-haHe who is temperate in his habits of eating, sleeping, working and recreation can mitigate all sorrows by practicing the yoga system.–Bhagavad Gita, Chapter 6, verse 17.The relevance of the Bhagavad Gita for modern psychotherapy has been widely reviewed.[11],[12] However, relatively little empirical literature exists on the effectiveness of versus spiritually integrated psychotherapy incorporating Hindu psychotherapeutic insights. Clearly, more work is needed, and buy antibiotics may provide an opportunity for conducting further empirical research.[13] In the meantime, using the principles outlined here may already be of benefit in helping those in need, and may be rapidly enabled in the emerging era of telehealth and digital health.[14]Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest.

References 1.Pandurangi AK, Shenoy S, Keshavan MS. Psychotherapy in the Bhagavad Gita, the Hindu scriptural text. Am J Psychiatry 2014;171:827-8. 2.Arango C. Lessons learned from the antibiotics health crisis in Madrid, Spain.

How buy antibiotics has changed our lives in the last 2 weeks [published online ahead of print, 2020 Apr 8]. Biol Psychiatry 2020;26:S0006-3223 (20) 31493-1. [doi. 10.1016/j.biopsych. 2020.04.003].

3.Keshavan MS, Gangadhar GN, Hinduism PA. In. Spirituality and Mental Health Across Cultures, Evidence-Based Implications for Clinical Practice. Oxford, England. Oxford University Press.

In Press. 4.Habersaat KB, Betsch C, Danchin M, Sunstein CR, Böhm R, Falk A, et al. Ten considerations for effectively managing the buy antibiotics transition. Nat Hum Behav 2020;4:677-87. Doi.

10.1038/s41562-020-0906-x. Epub 2020 Jun 24. 5.Kumar K. Building resilience to buy antibiotics disease severity. J Med Res Pract 2020;9:1-7.

6.Bushell W, Castle R, Williams MA, Brouwer KC, Tanzi RE, Chopra D, et al. Meditation and Yoga practices as potential adjunctive treatment of antibiotics and buy antibiotics. A brief overview of key subjects [published online ahead of print, 2020 Jun 22]. J Altern Complement Med 2020;26:10.1089/acm. 2020.0177.

[doi. 10.1089/acm. 2020.0177]. 7.Gupta H, Gupta M, Bhargava S. Potential use of turmeric in buy antibiotics [published online ahead of print, 2020 Jul 1].

Clin Exp Dermatol. 2020;10.1111/ced.14357. Doi:10.1111/ced.14357. 8.Damiot A, Pinto AJ, Turner JE, Gualano B. Immunological implications of physical inactivity among older adults during the buy antibiotics zithromax [published online ahead of print, 2020 Jun 25].

Gerontology 2020:26;1-8. [doi. 10.1159/000509216]. 9.El-Missiry MA, El-Missiry ZM, Othman AI. Melatonin is a potential adjuvant to improve clinical outcomes in individuals with obesity and diabetes with coexistence of buy antibiotics [published online ahead of print, 2020 Jun 29].

Eur J Pharmacol 2020;882:173329. 10.Mullington JM, Simpson NS, Meier-Ewert HK, Haack M. Sleep loss and inflammation. Best Pract Res Clin Endocrinol Metab 2010;24:775-84. 11.Balodhi JP, Keshavan MS.

Bhagavad Gita and psychotherapy. Asian J Psychiatr 2011;4:300-2. 12.Bhatia SC, Madabushi J, Kolli V, Bhatia SK, Madaan V. The Bhagavad Gita and contemporary psychotherapies. Indian J Psychiatry 2013;55:S315-21.

13.Keshavan MS. zithromaxs and psychiatry. Repositioning research in context of buy antibiotics [published online ahead of print, 2020 May 7]. Asian J Psychiatr 2020;51:102159. [doi.

10.1016/j.ajp. 2020.102159]. 14.Torous J, Keshavan M. buy antibiotics, mobile health and serious mental illness. Schizophr Res 2020;218:36-7.

Correspondence Address:Matcheri S KeshavanRoom 542, Massachusetts Mental Health Center, 75 Fenwood Road, Boston, MA 02115 USASource of Support. None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_829_20.

Zithromax for pneumonia treatment

Abstract Sexual health, an essential component of individual's health, is influenced by many complex issues including sexual behavior, attitudes, societal, zithromax for pneumonia treatment 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 zithromax for pneumonia treatment coined by Dr. N. N.

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

There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature. It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.Keywords. Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome.

A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr. President, Chairpersons, my respected teachers and seniors, my professional colleagues and friends, ladies and gentlemen:I deem it a proud privilege and pleasure to receive and to deliver DLN Murti Rao Oration Award for 2020. I am humbled at this great honor and remain grateful to the Indian Psychiatric Society (IPS) in general and the awards committee in particular. I would like to begin my presentation with my homage to Professor DLN Murti Rao, who was a Doyen of Psychiatry.[1] I have a special connection to the name as Dr.

Doddaballapura Laxmi Narasimha Murti Rao, apart from a family name, obtained his medical degree from Mysore Medical College, Mysuru, India, the same city where I have served last 33 years in JSS Medical College and JSS Academy of Higher Education and Research. His name carries the reverence in the corridors of the current National Institute of Mental Health and Neuro Sciences (NIMHANS) at Bangalore which was All India Institute of Mental Health, when he served as Head and the Medical Superintendent. Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS). Even though Dr.

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

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

People have variously attributed DS to excessive masturbation, premarital sex, promiscuity, and nocturnal emissions. Several past studies have emphasized that CBS leads to “anxiety for loss of semen” is not only prevalent in the Indian subcontinent but also a global phenomenon.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]It is important to note that DS manifestation and the psychosexual features are based on the impact of culture, demographic profiles, and the socioeconomic status of the patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] According to Leff,[21] culture depends upon norms, values, and myths, based on a specific area, and is also shared by the indigenous individuals of that area. Tiwari et al.[22] mentioned in their study that “culture is closely associated with mental disorders through social and psychological activities.” With this background, the paper attempts to highlight the multidimensional construct of DS for a better clinical understanding in routine practice. Dhat Syndrome. A Separate Entity or a “Cultural Variant” of Depression Even though DS has been studied for years now, a consensus on the definition is yet to be achieved.

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

There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders. Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue. Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively. Depression continued to be reported as the most common association of DS in many studies.[25],[26] This “cause-effect” dilemma can never be fully resolved.

Whether “loss of semen” and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument. However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness. Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management. He also mentions that the underlying “emotional distress and cultural contexts” are not unique to DS but can be related to any psychiatric syndrome for that matter. On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of “mood disorders” can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS.

Considering it as a variant of depression or somatization can make it a “cultural phenotype” of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients. Why Discuss Dhat Syndrome. Implications in Clinical Practice DS might occur independently or associated with multiple comorbidities. It has been a widely recognized clinical condition in various parts of the world, though considered specific to the Indian subcontinent.

The presentation can often be polymorphic with symptom clusters of affective, somatic, behavioral, and cognitive manifestations.[29] Being common in rural areas, the first contacts of the patients are frequently traditional faith healers and less often, the general practitioners. A psychiatric referral occurs much later, if at all. This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder. Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders.

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

Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as “semen loss syndrome” by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with “semen loss anxiety” suffer from a myriad of psychosexual symptoms, which have been attributed to “loss of vital essence through semen” (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale. The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms. Most commonly associated symptoms were found as per score ≥1. This study reported several parameters such as the “sense of being unhealthy” (99%), worry (99%), feeling “no improvement despite treatment” (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%).

The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness. Overall distress and dysfunction were observed as 64% and 81% in the studied subjects, respectively.A study in Taiwan involved 87 participants from a Urology clinic. Most of them have sexual neurosis (Shen-K'uei syndrome).[7] More than one-third of the patients belonged to lower social class and symptoms of depression, somatization, anxiety, masturbation, and nocturnal emissions. Other bodily complaints as reported were sleep disturbances, fatigue, dizziness, backache, and weakness.

Nearly 80% of them considered that all of their problems were due to masturbatory practices.De Silva and Dissanayake[8] investigated several manifestations on semen loss syndrome in the psychiatric clinic of Colombo General Hospital, Sri Lanka. Beliefs regarding effects of semen loss and help-seeking sought for DS were explored. 38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years. Every participant reported excessive loss of semen and was preoccupied with it.

The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss. Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing “Dhat” in urine. They were assessed for a period of 6 months.

More than 80% of them complained of body weakness, aches, and pains. More than 50% of the patients suffered from depression and anxiety. All the participants felt that their symptoms were due to loss of “dhat” in urine, attributed to excessive masturbation, extramarital and premarital sex. Half of those who faced sexual dysfunctions attributed them to semen loss.Mumford[11] proposed a controversial explanation of DS arguing that it might be a part of other psychiatric disorders, like depression. A total of 1000 literate patients were recruited from a medical outdoor in a public sector hospital in Lahore, Pakistan.

About 600 educated patients were included as per Bradford Somatic Inventory (BSI). Men with DS reported greater symptoms on BSI than those without DS. 60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for “Dhat” items on BSI. The symptoms persisted for more than 15 days.

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

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

One-third of the cases (32.8%) had no comorbidity in hospital (urban). One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction. The psychosexual symptoms were found among 113 patients who had DS. The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%). In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B.

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

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

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

Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia). Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India. They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic.

Clinical assessments were done apart from detailed sexual history. The patients were 15–50 years of age, educated up to mid-school and mostly from a rural background. Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age. There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation.

The authors stated that DS in India is a symptom complex commonly found in younger age groups (16–23 years). The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill. It was assumed in the study that semen loss is considered synonymous to “loss of something precious”, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and “Dhat” in urine (40%) were the common complaints observed. Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache.

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

67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%). Hypochondriasis, sexually transmitted diseases, and depression were the associated comorbidities. Morrone et al.[50] studied 18 male patients with DS in the Dermatology department who were from Bangladesh and India. The symptoms observed were mainly fatigue and nonspecific somatic symptoms.

DS patients manifested several symptoms in psychosocial, religious, somatic, and other domains. The reasons provided by the patients for semen loss were urinary loss, nocturnal emission, and masturbation. Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas. In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%–66.7%) were from rural areas, belonged to “conservative families and posed rigid views about sex” (69%-73%).

De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class. Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss. They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment.

The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class. Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%). The subjects were single or unmarried (51.0%) and married (46.7%). About 23.5% of the subjects had graduated and most were unemployed (73.5%).

Majority of subjects were lower-middle class (34%) and had lower incomes. Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%). About 45.80% of the study subjects were illiterates and very few had completed postgraduation. The subjects were both married and single. Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone.

Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%). Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16–20 years (34%) followed by 21–25 years (28%), greater than 30 years (26%), 26–30 years (10%), and 11–15 years (2%).

Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively. Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine. In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years. The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%).

Priyadarshi and Verma[43] performed a study in 110 male patients with DS. The average age of the patients was 23.53 years and it ranged between 15 and 68 years. The most affected age group of patients was of 18–25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years. Higher percentage of the patients were unmarried (70%).

Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively. Two-third patients belonged to rural areas of residence. Behere and Nataraj[45] found majority of the patients with DS (68%) to be between 16 and 25 years age. About 52% patients were married while 48% were unmarried and from lower socioeconomic strata.

The duration of DS symptoms varied widely. Singh[46] studied patients those who reported with DS, impotence, and premature ejaculation and reported the average age of the affected to be 21.8 years with a younger age of onset. Only a few patients received higher education. Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single.

It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training. Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%). Most of those who had comorbid DS symptoms received minimal formal education. Management. A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks.

As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal “supplements,” etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help. The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals. Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone.

Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality. This needs to be tailored to the local terminology and beliefs. Biofeedback has also been proposed as a treatment modality.[4] Individual stress factors that might have precipitated DS need to be addressed. A detailed outline of assessment, evaluation, and management of DS is beyond the scope of this article and has already been reported in the IPS Clinical Practice Guidelines.[56] The readers are referred to these important guidelines for a comprehensive read on management.

Probably, the most important factor is to understand and resolve the sociocultural contexts in the genesis of DS in each individual. Adequate debunking of the myths related to sexuality and culturally appropriate sexual education is vital both for the prevention and treatment of DS.[56] Adequate treatment of comorbidities such as depression and anxiety often helps in reduction of symptoms, more so when the DS is considered to be a manifestation of the same. Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary. CBS like DS forms a major area of this nosological controversy.

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

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

Conclusion DS is a multidimensional psychiatric “construct” which is equally interesting and controversial. Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality. Beyond the traditional debate about its “separate” existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health. It is also treatable, and hence, the detection, understanding, and awareness become vital to its management. This oration attempts a “bird's eye” view of this CBS taking into account a holistic perspective of the available evidence so far.

The clinical manifestations, diagnostic and epidemiological attributes, management, and nosological controversies are highlighted to provide a comprehensive account of DS and its relevance to mental health. More systematic and mixed methods research are warranted to unravel the enigma of this controversial yet distressing psychiatric disorder.AcknowledgmentI sincerely thank Dr. Debanjan Banerjee (Senior Resident, Department of Psychiatry, NIMHANS, Bangalore) for his constant selfless support, rich academic discourse, and continued collaboration that helped me condense years of research and ideas into this paper.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.2.3.Srinivasa Murthy R, Wig NN. A man ahead of his time.

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

Mysuru, India. Ramya Creations. 2015. P. 753-76.

4.Prakash O. Lessons for postgraduate trainees about Dhat syndrome. Indian J Psychiatry 2007;49:208-10. [PUBMED] [Full text] 5.Prakash S, Sharan P, Sood M. A study on phenomenology of Dhat syndrome in men in a general medical setting.

Indian J Psychiatry 2016;58:129-41. [PUBMED] [Full text] 6.Jadhav S. Dhāt syndrome. A re-evaluation. Psychiatry 2004;3:14-16.

7.Wen JK, Wang CL. Shen-Kui syndrome. A culture-specific sexual neurosis in Taiwan. In. Kleinman A, Lin TY, editors.

Normal and Abnormal Behaviour in Chinese Culture. Dordrecht, Holland. D Reidel Publishing Co. 1980. P.

357-69. 8.De Silva P, Dissanayake SA. The use of semen syndrome in Sri Lanka. A clinical study. Sex Marital Ther 1989;4:195-204.

9.Chadda RK, Ahuja N. Dhat syndrome. A sex neurosis of the Indian subcontinent. Br J Psychiatry 1990;156:577-9. 10.Rao TS, Rao VS, Rajendra PN, Mohammed A.

A retrospective comparative study of teaching hospital and private clinic clients with sexual problems. Indian J Behav Sci 1995;5:58-63. 11.Mumford DB. The 'Dhat syndrome'. A culturally determined symptom of depression?.

Acta Psychiatr Scand 1996;94:163-7. 12.Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes. The story of Dhat syndrome. Br J Psychiatry 2004;184:200-9.

13.Khan N. Dhat syndrome in relation to demographic characteristics. Indian J Psychiatry 2005;47:54-57. [Full text] 14.Prakash O, Kar SK, Sathyanarayana Rao TS. Indian story on semen loss and related Dhat syndrome.

Indian J Psychiatry 2014;56:377-82. [PUBMED] [Full text] 15.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al. Phenomenology and beliefs of patients with Dhat syndrome. A nationwide multicentric study. Int J Soc Psychiatry 2016;62:57-66.

16.MacFarland AS, Al-Maashani M, Al Busaidi Q, Al-Naamani A, El-Bouri M, Al-Adawi S. Culture-specific pathogenicity of Dhat (semen loss) Syndrome in an Arab/Islamic Society, Oman. 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 – 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, Martín-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 – 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.

Abstract Sexual health, an essential component of individual's health, is influenced by many complex buy cheap zithromax online issues including sexual behavior, attitudes, societal, and Buy generic levitra from canada 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 buy cheap zithromax online coined by Dr.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In. Sathyanarayana Rao TS, Tandon A, editors. Psychiatry in India.

Training and Training Centres. 2nd ed. Mysuru, India.

753-76. 4.Prakash O. Lessons for postgraduate trainees about Dhat syndrome.

Indian J Psychiatry 2007;49:208-10. [PUBMED] [Full text] 5.Prakash S, Sharan P, Sood M. A study on phenomenology of Dhat syndrome in men in a general medical setting.

Indian J Psychiatry 2016;58:129-41. [PUBMED] [Full text] 6.Jadhav S. Dhāt syndrome.

A re-evaluation. Psychiatry 2004;3:14-16. 7.Wen JK, Wang CL.

Shen-Kui syndrome. A culture-specific sexual neurosis in Taiwan. In.

Kleinman A, Lin TY, editors. Normal and Abnormal Behaviour in Chinese Culture. Dordrecht, Holland.

357-69. 8.De Silva P, Dissanayake SA. The use of semen syndrome in Sri Lanka.

A clinical study. Sex Marital Ther 1989;4:195-204. 9.Chadda RK, Ahuja N.

Dhat syndrome. A sex neurosis of the Indian subcontinent. Br J Psychiatry 1990;156:577-9.

10.Rao TS, Rao VS, Rajendra PN, Mohammed A. A retrospective comparative study of teaching hospital and private clinic clients with sexual problems. Indian J Behav Sci 1995;5:58-63.

11.Mumford DB. The 'Dhat syndrome'. A culturally determined symptom of depression?.

Acta Psychiatr Scand 1996;94:163-7. 12.Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes.

The story of Dhat syndrome. Br J Psychiatry 2004;184:200-9. 13.Khan N.

Dhat syndrome in relation to demographic characteristics. Indian J Psychiatry 2005;47:54-57. [Full text] 14.Prakash O, Kar SK, Sathyanarayana Rao TS.

Indian story on semen loss and related Dhat syndrome. Indian J Psychiatry 2014;56:377-82. [PUBMED] [Full text] 15.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al.

Phenomenology and beliefs of patients with Dhat syndrome. A nationwide multicentric study. Int J Soc Psychiatry 2016;62:57-66.

16.MacFarland AS, Al-Maashani M, Al Busaidi Q, Al-Naamani A, El-Bouri M, Al-Adawi S. Culture-specific pathogenicity of Dhat (semen loss) Syndrome in an Arab/Islamic Society, Oman. 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 – 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.

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, Martín-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 – 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.

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.

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.

Where can i buy zithromax over the counter usa

TAHLEQUAH, Okla where can i buy zithromax over the counter usa http://geolistening.com/where-can-i-buy-kamagra-jelly/. €” The history between largely rural states and Native American communities is filled with broken promises and surrendered land.In a small town in Oklahoma, a state university and the Cherokee Nation have launched the nation’s first tribally affiliated medical school by seeing what rural and tribal America have in common.An unlikely story?. Just ask Alex Cosby, a current student at the school.“If you had told me 10 years ago there’d be a where can i buy zithromax over the counter usa medical school with state-of-the-art equipment and a state-of-the-art outpatient center," Cosby said, "I’d say, ‘Tahlequah?. That’s gonna be in Tahlequah?. €™â€Tahlequah is the capital of the Cherokee Nation, which covers 9,000 square miles in where can i buy zithromax over the counter usa northeast Oklahoma.

Cosby is a student at Oklahoma State University’s College of Osteopathic Medicine, a collaboration between OSU and the Cherokee Nation. That statement makes where can i buy zithromax over the counter usa history. But the history behind it is what makes it such a statement.“If you went back a century, you wouldn’t predict it," said Chuck Hoskin, Jr., principal chief of the Cherokee Nation.“You would say, ‘Look, this is a relationship that can never be healed and perhaps the Indian nations will vanish,' which was the intent of some of those policies. We didn’t where can i buy zithromax over the counter usa vanish. We’re still here.

The best where can i buy zithromax over the counter usa friends the state of Oklahoma’s ever had.”The story of the Cherokee Nation is far too familiar for Native tribes. A story of broken treaties and forced surrender of land to the U.S. Government. But in recent years, the Cherokee Nation has poured resources into health care, for reasons its non-tribal neighbors know well.“If you’re in a rural part of the country," Hoskin said, "what you’re going to find is you’re going to find health care facilities that in some cases withering on the vine in terms of their ability to stay in business. It affects us because that’s where we’re recruiting.”The Cherokee Nation has built the largest tribal health care system in the country.

They use federal funds and their own funds to provide free health care for their citizens. They've spent hundreds of millions of dollars on new facilities.But a medical school offers not just care but a chance for careers.“In some counties in Oklahoma, they may have one primary care physician or no primary care physicians," said Dr. Kayse Shrum, president of Oklahoma State University. €œFor us, it was serving and educating rural and underserved Oklahoma. And for the tribes, it was about improving access and quality of care.”Dr.

Shrum was dean of the College of Osteopathic Medicine before she took over as university president. She helped engineer the collaboration with leaders at the Cherokee Nation.“I didn’t know any physicians as family friends or on a personal level really, outside of appointments," Cosby said.But he signed up for biology in college and got an A. He kept going and kept thriving. Now, he’s in position to be that physician the next generation knows.“I hope people can see that no matter what your background is, no matter what conditions you’re dealing with, you can succeed in life," he said.“A doctor, statistically, is going to practice within about 100 miles of where she gets her medical education," Hoskin said. "And that worked against us for the longest time.

If you flip the script, and you train people in a world-class medical school in Tahlequah, you start to change what those statistics mean.”Today in Tahlequah, a big orange O-S-U enmeshes with Cherokee text. Rural America meets tribal America because, for the most part, tribal America is rural America. Painful history has healed enough for an important union..

TAHLEQUAH, Okla buy cheap zithromax online. €” The history between largely rural states and Native American communities is filled with broken promises and surrendered land.In a small town in Oklahoma, a state university and the Cherokee Nation have launched the nation’s first tribally affiliated medical school by seeing what rural and tribal America have in common.An unlikely story?. Just ask Alex Cosby, a current student at the school.“If you had told me 10 years ago there’d be a medical buy cheap zithromax online school with state-of-the-art equipment and a state-of-the-art outpatient center," Cosby said, "I’d say, ‘Tahlequah?. That’s gonna be in Tahlequah?. €™â€Tahlequah is the capital buy cheap zithromax online of the Cherokee Nation, which covers 9,000 square miles in northeast Oklahoma.

Cosby is a student at Oklahoma State University’s College of Osteopathic Medicine, a collaboration between OSU and the Cherokee Nation. That statement makes buy cheap zithromax online history. But the history behind it is what makes it such a statement.“If you went back a century, you wouldn’t predict it," said Chuck Hoskin, Jr., principal chief of the Cherokee Nation.“You would say, ‘Look, this is a relationship that can never be healed and perhaps the Indian nations will vanish,' which was the intent of some of those policies. We didn’t buy cheap zithromax online vanish. We’re still here.

The best buy cheap zithromax online friends the state of Oklahoma’s ever had.”The story of the Cherokee Nation is far too familiar for Native tribes. A story of broken treaties and forced surrender of land to the U.S. Government. But in recent years, the Cherokee Nation has poured resources into health care, for reasons its non-tribal neighbors know well.“If you’re in a rural part of the country," Hoskin said, "what you’re going to find is you’re going to find health care facilities that in some cases withering on the vine in terms of their ability to stay in business. It affects us because that’s where we’re recruiting.”The Cherokee Nation has built the largest tribal health care system in the country.

They use federal funds and their own funds to provide free health care for their citizens. They've spent hundreds of millions of dollars on new facilities.But a medical school offers not just care but a chance for careers.“In some counties in Oklahoma, they may have one primary care physician or no primary care physicians," said Dr. Kayse Shrum, president of Oklahoma State University. €œFor us, it was serving and educating rural and underserved Oklahoma. And for the tribes, it was about improving access and quality of care.”Dr.

Shrum was dean of the College of Osteopathic Medicine before she took over as university president. She helped engineer the collaboration with leaders at the Cherokee Nation.“I didn’t know any physicians as family friends or on a personal level really, outside of appointments," Cosby said.But he signed up for biology in college and got an A. He kept going and kept thriving. Now, he’s in position to be that physician the next generation knows.“I hope people can see that no matter what your background is, no matter what conditions you’re dealing with, you can succeed in life," he said.“A doctor, statistically, is going to practice within about 100 miles of where she gets her medical education," Hoskin said. "And that worked against us for the longest time.

If you flip the script, and you train people in a world-class medical school in Tahlequah, you start to change what those statistics mean.”Today in Tahlequah, a big orange O-S-U enmeshes with Cherokee text. Rural America meets tribal America because, for the most part, tribal America is rural America. Painful history has healed enough for an important union..