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(SACRAMENTO) Centro Integral del CÃ¡ncer de UC Davis espera ayudar a las comunidades de habla hispana how to get prescribed viagra a entender cÃ³mo prevenir y tratar el cÃ¡ncer a travÃ©s de una serie de conversaciones en lÃnea llamadas âCharlas en espaÃ±ol, entendiendo el cÃ¡ncer en los latinosâ. Los foros virtuales gratuitos, conducidos en espaÃ±ol, fueron creados por la iniciativa del centro de cÃ¡ncer llamada LUCHA (Latinos Unidos para el Avance de la Salud del CÃ¡ncer). Estos eventos ofrecen informaciÃ³n educativa bÃ¡sica sobre how to get prescribed viagra el cÃ¡ncer y generan una conversaciÃ³n para que los expertos puedan responder directamente a las preguntas de los participantes. Click for the LUCHA flyer (PDF)âQueremos que la comunidad participe de nuestras conversaciones informales llamadas âcharlasâ para que se sientan cÃ³modos haciÃ©ndoles preguntas a los expertos y compartiendo lo que les preocupeâ, dijo el director de LUCHA, Luis Carvajal-Carmona, quien estÃ¡ encabezando la serie con la codirectora de LUCHA, Laura Fejerman.

Este es el segundo aÃ±o que LUCHA ofrece las charlas en espaÃ±ol. Los presentadores este aÃ±o how to get prescribed viagra incluyen destacados especialistas latinos de cÃ¡ncer de UCSF, UCLA y Mayo Clinic. La serie se conduce via Zoom y la prÃ³xima charla serÃ¡ el 9 de noviembre de 5 p.m. A 7 p.m.

El foco serÃ¡ crear concientizaciÃ³n sobre ensayos clÃnicos de cÃ¡ncer en las comunidades latinas y how to get prescribed viagra de habla hispana. RegÃstrese para las charlas en espaÃ±ol el 9 de noviembre vÃa Eventbrite. Si tiene alguna pregunta, contÃ¡ctese con AngÃ©lica Perez a amiperez@ucdavis.edu. Las grabaciones de las âCharlas en espaÃ±ol, entendiendo el cÃ¡ncer en los latinosâ que se realizaron en octubre ahora estÃ¡n how to get prescribed viagra disponibles.

Impacto del erectile dysfunction treatment en conductas de prevenciÃ³n del cÃ¡ncer entre los latinos (Oct. 19)Iniciativas sobre el cÃ¡ncer de pecho para prevenir el cÃ¡ncer en las latinas (Oct. 26) Centro how to get prescribed viagra Integral del CÃ¡ncer de UC Davis El Centro Integral del CÃ¡ncer de UC Davis es el Ãºnico centro designado por el Instituto Nacional del CÃ¡ncer que presta servicios en el Valle Central y el Norte de California, una regiÃ³n de mÃ¡s de 6 millones de personas. Sus especialistas prestan atenciÃ³n integral y de calidad a mÃ¡s de 10,000 adultos y niÃ±os cada aÃ±o, y ofrecen a los pacientes acceso a mÃ¡s de 150 ensayos clÃnicos.

Su programa innovador de investigaciÃ³n cuenta con mÃ¡s de 280 cientÃficos de UC Davis, quienes trabajan en conjunto para facilitar el descubrimiento de nuevas tÃ©cnicas para diagnosticar y tratar el cÃ¡ncer. Los pacientes tienen acceso a una atenciÃ³n de vanguardia, incluyendo how to get prescribed viagra inmunoterapia y otros tratamientos especÃficos personalizados. Por medio de su Programa de ExtensiÃ³n Comunitaria y Educativa, el Centro apunta a reducir las desigualdades en los resultados del tratamiento del cÃ¡ncer en distintas comunidades Ã©tnicas. AdemÃ¡s, el Centro brinda educaciÃ³n integral y programas de desarrollo de la fuerza laboral para la prÃ³xima generaciÃ³n de profesionales clÃnicos y cientÃficos.

A travÃ©s de la Red de AtenciÃ³n del CÃ¡ncer, UC Davis colabora con hospitales y centros de salud en todo el Valle Central how to get prescribed viagra y el Norte de California para ofrecerles a los pacientes con cÃ¡ncer los servicios mÃ¡s avanzados de atenciÃ³n en su zona. Para mayor informaciÃ³n, visite. Cancer.ucdavis.edu.

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STAT Plus is STAT's premium subscription service for in-depth biotech, pharma, policy, and life science coverage and analysis. Our award-winning team covers news on Wall Street, policy developments in Washington, early science breakthroughs and clinical trial results, and health care disruption in Silicon Valley viagra supplements and beyond. What's included?.

Daily reporting and analysis The most comprehensive industry coverage from a powerhouse team of reporters Subscriber-only newsletters Daily newsletters to brief you on the most important industry news of the day STAT+ Conversations Weekly opportunities to viagra supplements engage with our reporters and leading industry experts in live video conversations Exclusive industry events Premium access to subscriber-only networking events around the country The best reporters in the industry The most trusted and well-connected newsroom in the health care industry And much more Exclusive interviews with industry leaders, profiles, and premium tools, like our CRISPR Trackr.Good morning, everyone, and welcome to another working week. We hope the weekend respite was relaxing and invigorating, because that oh-so familiar routine of Zoom meeting, Skype calls, and deadlines has predictably returned. But what can you do? viagra supplements.

The world keeps spinning, despite the dizzying events occurring outside your door. To cope, yes, we are firing up the coffee kettle and viagra supplements brewing cups of stimulation. Our choice today is the seasonal pumpkin spice.

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Â¦The share of Americans who say they are likely to get a erectile dysfunction treatment as soon viagra supplements as itâs available is dropping â and the decline is notably more pronounced among Black Americans than among white individuals, according to a new survey from STAT and The Harris Poll. The survey found that 59% of white Americans indicated they would get vaccinated as soon as a treatment is ready, a decline from 70% in mid-August. Only 43% viagra supplements of Black individuals said they would pursue a treatment as soon as it was available, a sharp drop from 65% in mid-August.

Unlock this article by subscribing to STAT Plus and enjoy your first 30 days free!. GET STARTED Log In | viagra supplements Learn More What is it?. STAT Plus is STAT's premium subscription service for in-depth biotech, pharma, policy, and life science coverage and analysis.

Our award-winning team covers news on Wall Street, policy developments in Washington, early science breakthroughs and clinical trial results, and viagra supplements health care disruption in Silicon Valley and beyond. What's included?. Daily reporting and analysis The most comprehensive industry coverage from a powerhouse team of reporters Subscriber-only newsletters Daily newsletters to brief you on the most important industry news of the day STAT+ Conversations Weekly opportunities to engage with our reporters and leading industry experts in live video conversations Exclusive industry events Premium access to subscriber-only networking events around the country The best reporters in the industry The most trusted and well-connected newsroom in the health care industry And much more Exclusive interviews with industry leaders, profiles, and premium tools, like our CRISPR Trackr.President Donald Trumpâs surprisingly rapid discharge from Walter Reed National Military Medical Center, coupled with conflicting and vague statements on his condition, has created a whirlwind of confusion among the public.

Thereâs a lot we donât know, such as how he was exposed to erectile dysfunction, the viagra that causes erectile dysfunction treatment, what kind of treatments he may still be viagra supplements receiving, and how effective they may be.But there is one thing we do know. His was absolutely preventable.In health care, the term ânever eventâ refers to a serious, preventable occurrence that could have severe implications for a patient. These are normally things like operating on the wrong knee, giving the wrong medication, or discharging an infant to the wrong person.advertisement In these far-from-normal times, we can now add to that list of examples the growing outbreak of viagra supplements erectile dysfunction treatment in Washington, D.C., where the president, First Lady, members of Congress, the White House press secretary and other staff members, members of the media, and countless employees who support the operations of the U.S.

Government and the Trump reelection campaign were infected by the erectile dysfunction. Many point viagra supplements to the September 26 gathering in the White House Rose Garden to announce the nomination of Amy Coney Barrett to the Supreme Court as a potential âsuperspreaderâ event. Crowds of people were in close proximity, shaking hands and hugging.

Many were not wearing masks.advertisement Why frame the viagra supplements outbreak as a never event?. Because it meets all the criteria that the National Quality Forum uses to define one, and thinking of it that way points toward changes we can make to keep such contagion from happening in other settings. It was serious because of the potential impact of viagra supplements erectile dysfunction treatment, especially in older individuals and those with pre-existing conditions.

It was preventable because strategies to reduce the risk of â such as mask wearing and social distancing â are known and have been disseminated by the Centers for Disease Control and Prevention, an agency of the U.S. Government, yet were widely ignored. It was of concern because the hospitalization of the president and the broader impact on viagra supplements our government resulting from this outbreak posed a threat to our national security.Never events are opportunities for learning.

When they happen in the health care setting, the care team and health system leadership should do a careful analysis of what happened, why it happened, and what can be done to ensure it never happens again. The focus begins on the system in which care is delivered â viagra supplements not on individuals working in that system â because most errors are the result of flawed systems. That said, failing to follow policies and procedures in well-designed systems can also lead to adverse events.

Never events represent an open invitation to those in health care to speak candidly, regardless of who might be viagra supplements offended, about how things could and should be different.What we know so far is that despite CDC recommendations about the use of masks and physical distancing, events held at the White House and on behalf of the presidentâs reelection effort disregarded the guidance. Use of masks was cast as a âpersonal choice.â A significant number of attendees at the Rose Garden gathering did not wear masks, and a number of them have now tested positive for erectile dysfunction treatment. The White House grounds are tightly controlled viagra supplements.

Who comes, who goes, where they go when they are there, and what conditions they have to meet to gain access are entirely within the control of White House administrative leadership. The White House Medical Office and administrative team have an obligation to ensure that the risk of erectile dysfunction treatment viagra supplements to the president, his family, and his staff is as low as possible. Medical science gave them a variety of tools to do that â including wearing masks and social distancing â the same ones the CDC recommends for keeping the rest of us safe.

Following medical guidance is viewed by many as a choice that infringes personal freedom.The Presidentâs illness can and should be a wake-up call to even the viagra supplements most ardent skeptics that this is a serious disease and can affect any of us. We disregard medical science at our individual and collective peril.It is also a wake-up call to physicians everywhere that they must be careful not to allow their voices to be silenced because of operational, financial, or political considerations. At this time of national uncertainty, physician voices clearly informed by the best science are viagra supplements essential for our ability to survive and thrive as a society.

Silence undermines our fundamental commitment to our patients and the public good. If we as a society confuse medical science and politics, the outcomes are viagra supplements on full display at the White House for the whole country to see. History has shown that when knowledgeable professionals bow to political pressure or orders from the top, bad things can happen.We hope that this highly public never event causes the country â and the many medical professionals in leadership roles around the country â to recognize the consequences of the politicization and marginalization of medical science.Every time physicians permit institutions to warp the science they use to guide their care for patients, whether it is policies of insurance companies or hospital systems or the White House, trust in all physicians is eroded.

As we try to navigate viagra supplements our way through this viagra, trust is one of the most precious commodities we have.It is terrifying to see our leaders and our neighbors laid low by this viagra. Letâs not compound confusion by subverting the knowledge and expertise on which we all need to rely.Richard J. Baron is a geriatrician and internist and CEO of the American Board of Internal Medicine and the ABIM Foundation.

Marianne M viagra supplements. Green is an internist and geriatrician, vice dean for education at Northwestern University Feinberg School of Medicine, and chair of the American Board of Internal Medicine Board of Directors. Yul D viagra supplements.

Ejnes is an internal medicine physician with Coastal Medical, Inc. In Rhode Island and chair-elect of the American Board of Internal Medicine Board of Directors.The Centers for Medicare and Medicaid Services (CMS) recently issued a draft rule that could dramatically improve access to viagra supplements evidence-based treatments that can be delivered virtually. But it wonât unless CMS makes another seemingly simple change regarding benefit categories.erectile dysfunction treatment has web link killed more than 180,000 Medicare beneficiaries to date, representing about 80% of all erectile dysfunction treatment deaths in the U.S.

That means thereâs a pressing need for safe and viagra supplements effective socially distanced digital therapeutics.The Medicare Coverage for Innovative Technology (MCIT) proposed rule would cover the use of medical devices designated as âbreakthroughâ technologies as soon as they are approved by the U.S. Food and Drug Administration. That represents a viagra supplements big change.

These technologies are currently reviewed and approved by the various Medicare contractors responsible for each of Medicareâs several multi-state regions. This process can take years and may lead to a technology being covered in one region and not in another.advertisement The viagra supplements current coding, coverage, and payment processes are complex and CMS has acknowledged it has challenges keeping coverage determinations on pace with device innovation. The proposed rule (comments can be made on it through November 2, 2020) would potentially cover everything from the Orteq artificial knee meniscus and the Thermedical radiofrequency ablation catheter to treat ventricular tachycardia to digital therapeutics â evidence-based interventions driven by high quality software programs to prevent, manage, or treat a medical disorder or disease.

One promising breakthrough-designated digital therapeutic that could be affected by the proposed rule is MedRhythms, a platform for treating chronic stroke symptoms.advertisement The hitch for digital therapeutics is that, under Medicareâs outdated interpretation of regulatory language, digital therapeutics do not have a benefit category recognized by CMS, which is a requirement for Medicare coverage under the proposed rule.Digital therapeutics are most commonly regulated under the Software as a Medical Device (SaMD) framework, which the FDA defines as software intended to be used for one or more medical purposes without being part of a hardware medical device.Medicare reimbursement for digital therapeutics could happen either of two ways.Congress could establish a Medicare benefit category for digital therapeutics, much as it established categories for mammography screening and other preventive benefits, home infusion therapy, and treatment services for opioid use disorder. A bill with bipartisan support, the Access to Prescription Digital viagra supplements Therapeutics Act of 2020, has been introduced into the U.S. Senate, but the congressional stalemate makes its advancement unlikely during this Congress.

While a legislative solution would be welcome, a more timely mechanism would be to have viagra supplements CMS use the Medicare Coverage for Innovative Technology rule to clearly state that the existing benefit category, durable medical equipment, which includes things like hospital-grade beds and wheelchairs, also applies to many digital therapeutics and that breakthrough-designated software as a medical device could be subject to this coverage and subsequent payment.Some commercial payers have successfully paid for digital therapeutics. One approach has been to create a digital formulary, such as Cignaâs Express Scripts partnering with companies like Propeller Health, a digital health platform for asthma and COPD. But in the absence of traditional Medicare coverage for software as a medical device, the payment approaches in the commercial space require significant recreating of the contractual wheel each time a technology manufacturer seeks to establish a business relationship with a new payer viagra supplements.

While CMS has made meaningful strides during the erectile dysfunction treatment viagra through its flexibility with telehealth, its outdated view on software as a medical device and digital therapeutics has limited its ability to close health gaps.CMS was understandably viagra supplements reluctant to cover digital therapeutics when they first emerged. This reticence stemmed from four root causes. First, Medicare staffers must thoroughly review the literature for new technologies and, by their innovative nature, early digital therapeutics initially had limited research.

Second, the Medicare program is obligated viagra supplements to avoid fraud, waste, and abuse to ensure good stewardship of taxpayer dollars. Third, CMS staff harbored residual fear from the Supreme Court hand slap in a decision about CMS rule-making procedural missteps in Allina v. Azar.

Fourth, CMSâs interpretation of the definition of what constitutes durable medical equipment is too concrete. (Iâve written elsewhere a more detailed analysis of CMSâs overly rigid interpretation of durable medical equipment.)These four drivers make CMS staff apprehensive to move out of their coding and coverage comfort zone.STAT e-bookHow technology is shaping the future of health careOur latest e-book includes all of STATâs coverage of the recent STAT Health Tech Summit. With more than 1 million Medicare beneficiaries having already contracted erectile dysfunction treatment â and more to come â and the emergence of post-erectile dysfunction treatment syndrome, the demand for safe and effective socially distanced digital therapeutics during and beyond erectile dysfunction treatment should push CMS out of its regulatory routine and habit.

The four barriers to CMSâs coverage and reimbursement for digital therapeutics are not only outdated but also stifle equitable access to care for millions of Americans amid this viagra.The rigor and quality of digital therapeutics has evolved dramatically over the last decade. The FDAâs evidence review of them should suffice for CMSâs need for proof of clinical effectiveness.There are other reasons for CMS to be on board with digital therapeutics. The digital exhaust from them is far more granular and real time than the analog paper trail for traditional durable medical equipment when used to detect and prevent fraud, waste, and abuse.

The need for virtual care existed before erectile dysfunction treatment and will persist beyond it. This viagra has served as a regulatory catalyst for advancing telehealth and, with the introduction of the Medicare Coverage for Innovative Technology proposed rule, erectile dysfunction treatment can trigger advances in other virtual modalities to meet the needs of Medicare beneficiaries.But for the initiative to have teeth and fulfill its intent, CMS must clearly state that the durable medical equipment benefit category applies to many digital therapeutics and that breakthrough-designated software as a medical device should be subject to this coverage and subsequent payment. Doing so would help eliminate disparities in treatment for Medicare beneficiaries and balance accountable chronic disease management with the need for social distancing in the erectile dysfunction treatment era and beyond.Andrey Ostrovsky is a pediatrician, managing partner at Social Innovation Ventures, and the former chief medical officer for the Center for Medicaid and CHIP Services.WASHINGTON â In North Carolina last week, President Trump told voters at a campaign rally not to fear erectile dysfunction treatment because theyâd soon have access to a erectile dysfunction âcure.â The experimental treatment, he told supporters the next day in Iowa, made him feel âlike Superman.â In Florida, he told seniors theyâd soon have access, for free, to the antibody therapy heâd received during his own bout with the viagra two weeks before.Itâs a significant shift.

Trump campaigned for months on the dubious pledge that a treatment would be available âbefore a very special date,â an open nod to Election Day. But as itâs become clear drug companies wonât help Trump deliver on a key campaign promise by Nov. 3, heâs largely dropped the aggressive treatment rhetoric.

Instead, heâs begun to campaign on equally lofty boasts of a erectile dysfunction treatment cure-all â even though the treatments remain unproven and unavailable to the general public.âWe have to get âem approved, and I want to get âem to the hospitals where people are feeling badly,â Trump said in a recent video. ÂThatâs much more important to me than the treatment.âadvertisement Trumpâs pivot to touting therapeutics underscores his desperation to claim that his government is making significant progress in combating the viagra. And it is an attempt, too, to turn his own erectile dysfunction treatment diagnosis from a weakness into a strength, bolstering the dangerous arguments that Americans shouldnât fear the viagra or let it âdominateâ their lives.âClearly, thereâs been a shift in what the President talks about,â said Walid Gellad, a physician and health policy professor at the University of Pittsburgh.

ÂThat may just be a factor of the personal experience, although clearly itâs also related to the reality of the treatment. I donât know which of those it is.âadvertisement Trumpâs latest comments have stoked additional fear among public health experts and scientists that Americans will take the presidentâs advice and largely ignore the viagra unfolding around them. Even as Trump campaigns regularly in front of thousands of mostly unmasked supporters, case rates are spiking across the country.

Â¦Trump has fixated particular on a treatment heâs referred to as âRegeneronâ â in fact, an as-yet-unnamed cocktail of antibodies being developed by Regeneron, a New York drug manufacturer. Trumpâs effusiveness even led the Lincoln Project, a coalition of Republicans opposed to his re-election bid, to publish a fake commercial mocking Trump for hawking an unproven cure.âYouâve got to open up your businesses, open up your schools,â Trump said at a campaign rally in North Carolina on Thursday. ÂWe have incredible therapeutics, we have incredible drugs, we have, in my opinion, a cure.

Because I took something, Regeneron, it was highly sophisticated stuff. The antibodies, and Eli Lilly makes an incredible drug.â Itâs unclear whether Americans are taking his words to heart. Trumpâs message, however, is clearly out of step with reality, given skyrocketing case rates and a corresponding increase in erectile dysfunction treatment hospitalizations.âI have not seen any polling on whether this latest fusillade of claims regarding that great drug âRegeneronâ has convinced anyone that there are cures out there, period, let alone readily available ones for the population,â said Peter Bach, a doctor and health policy researcher at Memorial Sloan-Kettering Cancer Center in New York.

ÂI canât remember how many times the boy had to cry wolf before he was ignored, but I am sure the president has exceeded that number by now, probably by severalfold.â Trumpâs tone regarding new erectile dysfunction treatment therapies has exceeded even his prior effusiveness regarding treatments. Since his release, Trump has attempted to convince Americans theyâll soon have access to the same level of treatment he received at Walter Reed.âWe have Regeneron, we have a very similar drug from Eli Lilly, and theyâre coming out, and weâre trying to get them on an emergency basis,â Trump said in a video posted to Twitter on Oct. 7, in which he said contracting erectile dysfunction may have been a blessing from God.

ÂWeâve authorized it, Iâve authorized it, and if youâre in the hospital and youâre feeling really bad, I think weâre going to work it so that you get âem, and youâre going to get âem free.â The promises ignore key context. The president is among a small handful of people around the world whoâve received access to the Regeneron antibody therapy outside the setting of a clinical trial. The Food and Drug Administration has not yet issued an emergency use authorization for either therapy â in fact, one trial testing Eli Lillyâs antibody treatment for hospitalized patients was recently paused following a potential safety concern.As with other once-touted erectile dysfunction treatments, however, Gellad said the presidentâs enthusiasm could do more harm than good, especially when it comes to the publicâs perception of the FDA.

First over the malaria drug hydroxychloroquine and again over the use of blood plasma from recovered erectile dysfunction treatment patients.âThe perception, and the reality, is that thereâs a lot of political interference, whether itâs addressing hydroxychloroquine, plasma, antibodies, or treatments,â Gellad said. ÂIn reality, all of these drugs might fit the criteria for what FDA would have done probably anyway.â.

Two state treasurers are urging Cardinal Health (CAH) shareholders to reject a hefty, $2.5 million bonus for the chief executive officer, citing his long-standing tenure at the wholesaler and its role in fomenting the opioid crisis.In a regulatory filing, the treasurers argued that Cardinal appeared to have how to get prescribed viagra âpersistently failedâ to ensure safe and secure distribution of controlled substances, and that rewarding chief executive officer Michael Kaufman would risk shareholder value and have negative implications for society as a whole. Unlock this article by subscribing to STAT Plus and enjoy your first 30 days free!. GET STARTED Log In | how to get prescribed viagra Learn More What is it?. STAT Plus is STAT's premium subscription service for in-depth biotech, pharma, policy, and life science coverage and analysis. Our award-winning team covers news on Wall Street, policy developments in Washington, early science how to get prescribed viagra breakthroughs and clinical trial results, and health care disruption in Silicon Valley and beyond.

What's included?. Daily reporting and analysis The most comprehensive industry coverage from a powerhouse team of reporters Subscriber-only newsletters Daily newsletters to brief you on the most important industry news of the day STAT+ Conversations Weekly opportunities to engage how to get prescribed viagra with our reporters and leading industry experts in live video conversations Exclusive industry events Premium access to subscriber-only networking events around the country The best reporters in the industry The most trusted and well-connected newsroom in the health care industry And much more Exclusive interviews with industry leaders, profiles, and premium tools, like our CRISPR Trackr.Good morning, everyone, and welcome to another working week. We hope the weekend respite was relaxing and invigorating, because that oh-so familiar routine of Zoom meeting, Skype calls, and deadlines has predictably returned. But what can you how to get prescribed viagra do?. The world keeps spinning, despite the dizzying events occurring outside your door.

To cope, yes, we are firing up the coffee kettle and how to get prescribed viagra brewing cups of stimulation. Our choice today is the seasonal pumpkin spice. Feel free to join us. Meanwhile, here are a few tidbits to help how to get prescribed viagra you get started. We hope your day is smashing, and do keep in touch.

Â¦The share of how to get prescribed viagra Americans who say they are likely to get a erectile dysfunction treatment as soon as itâs available is dropping â and the decline is notably more pronounced among Black Americans than among white individuals, according to a new survey from STAT and The Harris Poll. The survey found that 59% of white Americans indicated they would get vaccinated as soon as a treatment is ready, a decline from 70% in mid-August. Only 43% of Black individuals said they would pursue a treatment as soon as it was available, a sharp how to get prescribed viagra drop from 65% in mid-August. Unlock this article by subscribing to STAT Plus and enjoy your first 30 days free!. GET STARTED Log In | Learn how to get prescribed viagra More What is it?.

STAT Plus is STAT's premium subscription service for in-depth biotech, pharma, policy, and life science coverage and analysis. Our award-winning team covers how to get prescribed viagra news on Wall Street, policy developments in Washington, early science breakthroughs and clinical trial results, and health care disruption in Silicon Valley and beyond. What's included?. Daily reporting and analysis The most comprehensive industry coverage from a powerhouse team of reporters Subscriber-only newsletters Daily newsletters to brief you on the most important industry news of the day STAT+ Conversations Weekly opportunities to engage with our reporters and leading industry experts in live video conversations Exclusive industry events Premium access to subscriber-only networking events around the country The best reporters in the industry The most trusted and well-connected newsroom in the health care industry And much more Exclusive interviews with industry leaders, profiles, and premium tools, like our CRISPR Trackr.President Donald Trumpâs surprisingly rapid discharge from Walter Reed National Military Medical Center, coupled with conflicting and vague statements on his condition, has created a whirlwind of confusion among the public. Thereâs a lot we donât know, such as how he was exposed to erectile dysfunction, the viagra that how to get prescribed viagra causes erectile dysfunction treatment, what kind of treatments he may still be receiving, and how effective they may be.But there is one thing we do know.

His was absolutely preventable.In health care, the term ânever eventâ refers to a serious, preventable occurrence that could have severe implications for a patient. These are normally things like operating on the wrong knee, giving the wrong medication, or discharging an infant to the wrong person.advertisement In these far-from-normal times, we can now add to that list of examples the growing outbreak of erectile dysfunction treatment in Washington, D.C., where the president, First Lady, members of Congress, how to get prescribed viagra the White House press secretary and other staff members, members of the media, and countless employees who support the operations of the U.S. Government and the Trump reelection campaign were infected by the erectile dysfunction. Many point to the September how to get prescribed viagra 26 gathering in the White House Rose Garden to announce the nomination of Amy Coney Barrett to the Supreme Court as a potential âsuperspreaderâ event. Crowds of people were in close proximity, shaking hands and hugging.

Many were not wearing masks.advertisement Why frame the outbreak how to get prescribed viagra as a never event?. Because it meets all the criteria that the National Quality Forum uses to define one, and thinking of it that way points toward changes we can make to keep such contagion from happening in other settings. It was serious because of the potential impact of erectile dysfunction treatment, especially in older how to get prescribed viagra individuals and those with pre-existing conditions. It was preventable because strategies to reduce the risk of â such as mask wearing and social distancing â are known and have been disseminated by the Centers for Disease Control and Prevention, an agency of the U.S. Government, yet were widely ignored.

It was of concern because the hospitalization of the president and the broader impact on our government resulting from this outbreak posed a threat to our national security.Never events are how to get prescribed viagra opportunities for learning. When they happen in the health care setting, the care team and health system leadership should do a careful analysis of what happened, why it happened, and what can be done to ensure it never happens again. The focus begins on the system in which care is delivered â not on individuals working in that system how to get prescribed viagra â because most errors are the result of flawed systems. That said, failing to follow policies and procedures in well-designed systems can also lead to adverse events. Never events represent an open invitation to those in health care to speak candidly, regardless of who might be offended, about how things could and should be different.What we how to get prescribed viagra know so far is that despite CDC recommendations about the use of masks and physical distancing, events held at the White House and on behalf of the presidentâs reelection effort disregarded the guidance.

Use of masks was cast as a âpersonal choice.â A significant number of attendees at the Rose Garden gathering did not wear masks, and a number of them have now tested positive for erectile dysfunction treatment. The White House grounds how to get prescribed viagra are tightly controlled. Who comes, who goes, where they go when they are there, and what conditions they have to meet to gain access are entirely within the control of White House administrative leadership. The White how to get prescribed viagra House Medical Office and administrative team have an obligation to ensure that the risk of erectile dysfunction treatment to the president, his family, and his staff is as low as possible. Medical science gave them a variety of tools to do that â including wearing masks and social distancing â the same ones the CDC recommends for keeping the rest of us safe.

It appears that the failure occurred because clear medical science, including the advice of federal agencies, was disregarded, not just at the White House but in a variety of settings in which the president appeared.What does this mean for the rest of the country?. We are in how to get prescribed viagra the midst of a national political debate, with the president at the center, about our willingness to collectively adopt proven strategies that reduce the risk that any of us is infected with erectile dysfunction. The president himself has expressed skepticism about the seriousness of the disease and has declined to follow evidence-based medical advice with respect to his own appearances. Following medical guidance is viewed by many as a how to get prescribed viagra choice that infringes personal freedom.The Presidentâs illness can and should be a wake-up call to even the most ardent skeptics that this is a serious disease and can affect any of us. We disregard medical science at our individual and collective peril.It is also a wake-up call to physicians everywhere that they must be careful not to allow their voices to be silenced because of operational, financial, or political considerations.

At this time of national how to get prescribed viagra uncertainty, physician voices clearly informed by the best science are essential for our ability to survive and thrive as a society. Silence undermines our fundamental commitment to our patients and the public good. If how to get prescribed viagra we as a society confuse medical science and politics, the outcomes are on full display at the White House for the whole country to see. History has shown that when knowledgeable professionals bow to political pressure or orders from the top, bad things can happen.We hope that this highly public never event causes the country â and the many medical professionals in leadership roles around the country â to recognize the consequences of the politicization and marginalization of medical science.Every time physicians permit institutions to warp the science they use to guide their care for patients, whether it is policies of insurance companies or hospital systems or the White House, trust in all physicians is eroded. As we try to navigate our way through this viagra, trust is one of the most precious commodities we have.It is terrifying to see our leaders how to get prescribed viagra and our neighbors laid low by this viagra.

Letâs not compound confusion by subverting the knowledge and expertise on which we all need to rely.Richard J. Baron is a geriatrician and internist and CEO of the American Board of Internal Medicine and the ABIM Foundation. Marianne M how to get prescribed viagra. Green is an internist and geriatrician, vice dean for education at Northwestern University Feinberg School of Medicine, and chair of the American Board of Internal Medicine Board of Directors. Yul D how to get prescribed viagra.

Ejnes is an internal medicine physician with Coastal Medical, Inc. In Rhode Island and chair-elect of how to get prescribed viagra the American Board of Internal Medicine Board of Directors.The Centers for Medicare and Medicaid Services (CMS) recently issued a draft rule that could dramatically improve access to evidence-based treatments that can be delivered virtually. But it wonât unless CMS makes another seemingly simple change regarding benefit categories.erectile dysfunction treatment has killed more than 180,000 Medicare beneficiaries to date, representing about 80% of all erectile dysfunction treatment deaths in the U.S. That means thereâs a pressing need for safe and effective socially distanced digital therapeutics.The Medicare Coverage for Innovative Technology (MCIT) proposed rule would cover the use of medical devices designated as âbreakthroughâ technologies as soon as they are how to get prescribed viagra approved by the U.S. Food and Drug Administration.

That represents a how to get prescribed viagra big change. These technologies are currently reviewed and approved by the various Medicare contractors responsible for each of Medicareâs several multi-state regions. This process can take years and may lead to a technology being covered in one region and not in another.advertisement The current coding, coverage, and payment processes are complex and CMS how to get prescribed viagra has acknowledged it has challenges keeping coverage determinations on pace with device innovation. The proposed rule (comments can be made on it through November 2, 2020) would potentially cover everything from the Orteq artificial knee meniscus and the Thermedical radiofrequency ablation catheter to treat ventricular tachycardia to digital therapeutics â evidence-based interventions driven by high quality software programs to prevent, manage, or treat a medical disorder or disease. One promising breakthrough-designated digital therapeutic that could be affected by the proposed rule is MedRhythms, a platform for treating chronic stroke symptoms.advertisement The hitch for digital therapeutics is that, under Medicareâs outdated interpretation of regulatory language, digital therapeutics do not have a benefit category recognized by CMS, which is a requirement for Medicare coverage under the proposed rule.Digital therapeutics are most commonly regulated under the Software as a Medical Device (SaMD) framework, which the FDA defines as software intended to be used for one or more medical purposes without being part of a hardware medical device.Medicare reimbursement for digital therapeutics could happen either of two ways.Congress could establish a Medicare benefit category for digital therapeutics, much as it established categories for mammography screening and other preventive benefits, home infusion therapy, and treatment services for opioid use disorder.

A bill how to get prescribed viagra with bipartisan support, the Access to Prescription Digital Therapeutics Act of 2020, has been introduced into the U.S. Senate, but the congressional stalemate makes its advancement unlikely during this Congress. While a legislative solution would be welcome, a more timely mechanism would be to have CMS use the Medicare Coverage for Innovative Technology rule to how to get prescribed viagra clearly state that the existing benefit category, durable medical equipment, which includes things like hospital-grade beds and wheelchairs, also applies to many digital therapeutics and that breakthrough-designated software as a medical device could be subject to this coverage and subsequent payment.Some commercial payers have successfully paid for digital therapeutics. One approach has been to create a digital formulary, such as Cignaâs Express Scripts partnering with companies like Propeller Health, a digital health platform for asthma and COPD. But in how to get prescribed viagra the absence of traditional Medicare coverage for software as a medical device, the payment approaches in the commercial space require significant recreating of the contractual wheel each time a technology manufacturer seeks to establish a business relationship with a new payer.

This redundancy adds to the wasteful spending in the already overly expensive American health care system and delays evidence-based treatments from getting to the people who need them.Medicare has lagged behind commercial payers because it has not assigned or created a benefit category for digital therapeutics. This has further widened the equity gap for American seniors, people with disabilities, people with end-stage kidney disease, how to get prescribed viagra and other beneficiaries of traditional Medicare. To make matters worse, the erectile dysfunction treatment viagra has disproportionately affected Medicare beneficiaries, further worsening health disparities. While CMS has made meaningful strides during the erectile dysfunction treatment viagra through its flexibility with telehealth, its outdated view on software as a medical device and digital therapeutics has how to get prescribed viagra limited its ability to close health gaps.CMS was understandably reluctant to cover digital therapeutics when they first emerged. This reticence stemmed from four root causes.

First, Medicare staffers must thoroughly review the literature for new technologies and, by their innovative nature, early digital therapeutics initially had limited research. Second, the Medicare program how to get prescribed viagra is obligated to avoid fraud, waste, and abuse to ensure good stewardship of taxpayer dollars. Third, CMS staff harbored residual fear from the Supreme Court hand slap in a decision about CMS rule-making procedural missteps in Allina v. Azar. Fourth, CMSâs interpretation of the definition of what constitutes durable medical equipment is too concrete.

(Iâve written elsewhere a more detailed analysis of CMSâs overly rigid interpretation of durable medical equipment.)These four drivers make CMS staff apprehensive to move out of their coding and coverage comfort zone.STAT e-bookHow technology is shaping the future of health careOur latest e-book includes all of STATâs coverage of the recent STAT Health Tech Summit. With more than 1 million Medicare beneficiaries having already contracted erectile dysfunction treatment â and more to come â and the emergence of post-erectile dysfunction treatment syndrome, the demand for safe and effective socially distanced digital therapeutics during and beyond erectile dysfunction treatment should push CMS out of its regulatory routine and habit. The four barriers to CMSâs coverage and reimbursement for digital therapeutics are not only outdated but also stifle equitable access to care for millions of Americans amid this viagra.The rigor and quality of digital therapeutics has evolved dramatically over the last decade. The FDAâs evidence review of them should suffice for CMSâs need for proof of clinical effectiveness.There are other reasons for CMS to be on board with digital therapeutics. The digital exhaust from them is far more granular and real time than the analog paper trail for traditional durable medical equipment when used to detect and prevent fraud, waste, and abuse.

The data from digital therapeutics could also support continuous improvement in outcomes or reductions in health care system costs. The value of these data could be incorporated into Medicare coverage and payment decisions.In the Medicare Coverage for Innovative Technology proposal, CMS has appropriately followed rule-making protocol, thus protecting its staff from getting burned by the legal hot water of Allina v. Azar.And based on the CMS coding decision tree and regulatory definition of durable medical equipment, many breakthrough-designated digital therapeutics meet the criteria for creating a new or miscellaneous health care common procedure code which is needed for medical providers to submit health care claims to Medicare and other health insurance companies.According to CMS Administrator Seema Verma, reversing course on virtual care would be a mistake. The need for virtual care existed before erectile dysfunction treatment and will persist beyond it. This viagra has served as a regulatory catalyst for advancing telehealth and, with the introduction of the Medicare Coverage for Innovative Technology proposed rule, erectile dysfunction treatment can trigger advances in other virtual modalities to meet the needs of Medicare beneficiaries.But for the initiative to have teeth and fulfill its intent, CMS must clearly state that the durable medical equipment benefit category applies to many digital therapeutics and that breakthrough-designated software as a medical device should be subject to this coverage and subsequent payment.

Doing so would help eliminate disparities in treatment for Medicare beneficiaries and balance accountable chronic disease management with the need for social distancing in the erectile dysfunction treatment era and beyond.Andrey Ostrovsky is a pediatrician, managing partner at Social Innovation Ventures, and the former chief medical officer for the Center for Medicaid and CHIP Services.WASHINGTON â In North Carolina last week, President Trump told voters at a campaign rally not to fear erectile dysfunction treatment because theyâd soon have access to a erectile dysfunction âcure.â The experimental treatment, he told supporters the next day in Iowa, made him feel âlike Superman.â In Florida, he told seniors theyâd soon have access, for free, to the antibody therapy heâd received during his own bout with the viagra two weeks before.Itâs a significant shift. Trump campaigned for months on the dubious pledge that a treatment would be available âbefore a very special date,â an open nod to Election Day. But as itâs become clear drug companies wonât help Trump deliver on a key campaign promise by Nov. 3, heâs largely dropped the aggressive treatment rhetoric. Instead, heâs begun to campaign on equally lofty boasts of a erectile dysfunction treatment cure-all â even though the treatments remain unproven and unavailable to the general public.âWe have to get âem approved, and I want to get âem to the hospitals where people are feeling badly,â Trump said in a recent video.

ÂThatâs much more important to me than the treatment.âadvertisement Trumpâs pivot to touting therapeutics underscores his desperation to claim that his government is making significant progress in combating the viagra. And it is an attempt, too, to turn his own erectile dysfunction treatment diagnosis from a weakness into a strength, bolstering the dangerous arguments that Americans shouldnât fear the viagra or let it âdominateâ their lives.âClearly, thereâs been a shift in what the President talks about,â said Walid Gellad, a physician and health policy professor at the University of Pittsburgh. ÂThat may just be a factor of the personal experience, although clearly itâs also related to the reality of the treatment. I donât know which of those it is.âadvertisement Trumpâs latest comments have stoked additional fear among public health experts and scientists that Americans will take the presidentâs advice and largely ignore the viagra unfolding around them. Even as Trump campaigns regularly in front of thousands of mostly unmasked supporters, case rates are spiking across the country.

Over 700 Americans still die of erectile dysfunction treatment each day. Even amid the spikes, Trump has argued that Americans should return to business as usual, given the existence of the experimental therapies.Public health experts are still urging people to continue to follow social distancing guidelines and to wear masks in public. With the weather growing colder, Americans spending more time indoors, and the holiday travel season approaching, experts including Tony Fauci, the governmentâs leading infectious disease researcher, warn that failure to adhere to basic public health guidelines could have deadly consequences. Â¦Trump has fixated particular on a treatment heâs referred to as âRegeneronâ â in fact, an as-yet-unnamed cocktail of antibodies being developed by Regeneron, a New York drug manufacturer. Trumpâs effusiveness even led the Lincoln Project, a coalition of Republicans opposed to his re-election bid, to publish a fake commercial mocking Trump for hawking an unproven cure.âYouâve got to open up your businesses, open up your schools,â Trump said at a campaign rally in North Carolina on Thursday.

ÂWe have incredible therapeutics, we have incredible drugs, we have, in my opinion, a cure. Because I took something, Regeneron, it was highly sophisticated stuff. The antibodies, and Eli Lilly makes an incredible drug.â Itâs unclear whether Americans are taking his words to heart. Trumpâs message, however, is clearly out of step with reality, given skyrocketing case rates and a corresponding increase in erectile dysfunction treatment hospitalizations.âI have not seen any polling on whether this latest fusillade of claims regarding that great drug âRegeneronâ has convinced anyone that there are cures out there, period, let alone readily available ones for the population,â said Peter Bach, a doctor and health policy researcher at Memorial Sloan-Kettering Cancer Center in New York. ÂI canât remember how many times the boy had to cry wolf before he was ignored, but I am sure the president has exceeded that number by now, probably by severalfold.â Trumpâs tone regarding new erectile dysfunction treatment therapies has exceeded even his prior effusiveness regarding treatments.

Since his release, Trump has attempted to convince Americans theyâll soon have access to the same level of treatment he received at Walter Reed.âWe have Regeneron, we have a very similar drug from Eli Lilly, and theyâre coming out, and weâre trying to get them on an emergency basis,â Trump said in a video posted to Twitter on Oct. 7, in which he said contracting erectile dysfunction may have been a blessing from God. ÂWeâve authorized it, Iâve authorized it, and if youâre in the hospital and youâre feeling really bad, I think weâre going to work it so that you get âem, and youâre going to get âem free.â The promises ignore key context. The president is among a small handful of people around the world whoâve received access to the Regeneron antibody therapy outside the setting of a clinical trial. The Food and Drug Administration has not yet issued an emergency use authorization for either therapy â in fact, one trial testing Eli Lillyâs antibody treatment for hospitalized patients was recently paused following a potential safety concern.As with other once-touted erectile dysfunction treatments, however, Gellad said the presidentâs enthusiasm could do more harm than good, especially when it comes to the publicâs perception of the FDA.

Trump has already telegraphed that his administration will soon issue emergency authorizations for both the Regeneron and Eli Lilly antibody therapies. If the FDA does so, it might appear that Trumpâs rhetoric influenced the decision â even if the agencyâs scientists didnât factor in the presidentâs eagerness. The scenario has already played out twice in 2020, Gellad said. First over the malaria drug hydroxychloroquine and again over the use of blood plasma from recovered erectile dysfunction treatment patients.âThe perception, and the reality, is that thereâs a lot of political interference, whether itâs addressing hydroxychloroquine, plasma, antibodies, or treatments,â Gellad said. ÂIn reality, all of these drugs might fit the criteria for what FDA would have done probably anyway.â.

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Keep out of reach of children. Store at room temperature between 15 and 30 degrees C (59 and 86 degrees F). Throw away any unused medicine after the expiration date.

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As states frantically prepare to begin months of vaccinations that could end the viagra, a new poll finds only about half of can you take viagra if you have high blood pressure Americans are ready to roll up their sleeves when their turn comes.The survey from The Associated Press-NORC Center for Antabuse best buy Public Affairs Research shows about a quarter of U.S. Adults aren't sure if can you take viagra if you have high blood pressure they want to get vaccinated against the erectile dysfunction. Roughly another quarter say they won't.Many on the fence have safety concerns and want to watch how the initial rollout fares â skepticism that could hinder the campaign against the scourge that has killed nearly 290,000 Americans. Experts estimate at least can you take viagra if you have high blood pressure 70% of the U.S. Population needs to be vaccinated to achieve herd immunity, or the point at which can you take viagra if you have high blood pressure enough people are protected that the viagra can be held in check."Trepidation is a good word.

I have a little bit of trepidation towards it," said Kevin Buck, a 53-year-old former Marine from Eureka, California. Buck said can you take viagra if you have high blood pressure he and his family will probably get vaccinated eventually, if initial shots go well. "It seems like a little rushed, but I know there was absolutely a reason to rush can you take viagra if you have high blood pressure it," he said of the treatment, which was developed with remarkable speed, less than a year after the viagra was identified. "I think a lot of people are not sure what to believe, and I'm one of them."Amid a frightening surge in erectile dysfunction treatment that promises a bleak winter across the country, the challenge for health authorities is to figure out what it will take to make people trust the shots that Dr. Anthony Fauci, can you take viagra if you have high blood pressure the top U.S.

Infectious-disease expert, calls the light at can you take viagra if you have high blood pressure the end of the tunnel."If Dr. Fauci says it's good, I will do it," said Mary Lang, 71, of Fremont, California. She added can you take viagra if you have high blood pressure. "Hopefully if enough of us get the treatment, we can make this viagra go away."Early data suggests the two U.S. Frontrunners -- one treatment made by Pfizer and BioNTech and another by Moderna and the National Institutes of can you take viagra if you have high blood pressure Health -- offer strong protection.

The Food and Drug Administration is poring over study results to be sure the shots are safe before deciding in the coming days whether to allow mass vaccinations, as Britain can you take viagra if you have high blood pressure began doing with Pfizer's shots on Tuesday.Despite the hopeful news, feelings haven't changed much from an AP-NORC poll in May, before it was clear a treatment would pan out.In the survey of 1,117 American adults conducted Dec. 3-7, about 3 in 10 said they are very or extremely confident that the first available treatments will have been properly tested for safety and effectiveness. About an equal number said can you take viagra if you have high blood pressure they are not confident. The rest fell can you take viagra if you have high blood pressure somewhere in the middle. Experts have stressed that no corners were cut during development of the treatment, attributing the speedy work to billions in government funding and more than a decade of behind-the-scenes research.Among those who don't want to get vaccinated, about 3 in 10 said they aren't concerned about getting seriously ill from the erectile dysfunction, and around a quarter said the outbreak isn't as serious as some people say.About 7 in 10 of those who said they won't get vaccinated are concerned about side effects.

Pfizer and Moderna say testing has uncovered no serious ones so can you take viagra if you have high blood pressure far. As with many treatments, recipients may experience fever, fatigue or sore arms can you take viagra if you have high blood pressure from the injection, signs the immune system is revving up.But other risks might not crop up until treatments are more widely used. British health authorities are examining two possible allergic reactions on the first day the country began mass vaccinations with the Pfizer shot.Among Americans who won't get vaccinated, the poll found 43% are concerned the treatment itself could infect them â something that's scientifically impossible, since the shots don't contain any viagra. Protecting their family, their community and can you take viagra if you have high blood pressure their own health are chief drivers for people who want the treatment. Roughly three-quarters said life won't go back to normal until enough of the country can you take viagra if you have high blood pressure is vaccinated."Even if it helps a little bit, I'd take it," said Ralph Martinez, 67, who manages a grocery store in Dallas.

"I honestly think they wouldn't put something out there that would hurt us."Over the summer, about a third of Martinez's employees were out with erectile dysfunction treatment. He wears a mask daily but worries about the constant public contact and is concerned that his 87-year-old mother is similarly exposed running her business.erectile dysfunction treatment has killed or hospitalized Black, Hispanic and Native Americans can you take viagra if you have high blood pressure at far higher rates than white Americans. Yet 53% of white Americans said they will get vaccinated, compared with 24% of Black Americans and 34% of Hispanics like Martinez. Because of insufficient sample size, the survey could not analyze results among Native Americans or other racial and ethnic groups that make up can you take viagra if you have high blood pressure a smaller proportion of the U.S. Population.Horace Carpenter of Davenport, Florida, knows that as a Black man at age 86, he is can you take viagra if you have high blood pressure vulnerable.

"I'd like to see it come out first," he said of the treatment. But he said he, too, plans to follow Fauci's can you take viagra if you have high blood pressure advice.Given the nation's long history of racial health care disparities and research abuses against Black people, Carpenter isn't surprised that minority communities are more hesitant about the new treatments."There is such racial inequality in our society," he said. "There's bound to be some hiccups."Health experts say it is not surprising that people have doubts because it will take time for the treatments' study results to become widely known."Sometimes you have to ask people more than once," said John Grabenstein of the Immunization Action Coalition, a can you take viagra if you have high blood pressure retired Army colonel who directed the Defense Department's immunization program. He said many eventually will decide it's "far, far better to take this treatment than run the risk of erectile dysfunction ."Adding to the challenge are political divisions that have hamstrung public health efforts to curtail the outbreak. The poll found 6 in 10 Democrats said they will can you take viagra if you have high blood pressure get vaccinated compared with 4 in 10 Republicans.

About a third of Republicans said they won't.Only about 1 in 5 Americans are very or extremely confident that treatments will be safely and quickly distributed, or fairly distributed, though majorities are at least somewhat confident.Nancy Nolan, 64, teaches English as a second language can you take viagra if you have high blood pressure at a New Jersey community college and has seen the difficulty her students face in getting erectile dysfunction testing and care. "I don't think it'll be fairly distributed," she said. "I hope I'm wrong." She can you take viagra if you have high blood pressure raised concerns, too, over the speed with which the treatment was developed. "If I rush, I could have a car accident, I could make a mistake." Health workers and nursing home residents are set to be first in line for the scarce initial doses. Plans call for other essential workers and people over 65 or at increased risk because of other health problems to follow, before enough treatment arrives for everyone, probably in the spring.The poll found majorities of Americans agree with that can you take viagra if you have high blood pressure priority list.

And 59% think vaccinating teachers should be a can you take viagra if you have high blood pressure high priority, too. Most also agree with higher priority for hard-hit communities of color and people in crowded living conditions such as homeless shelters and college dorms."Once those individuals are cared for, I wouldn't hesitate to get the treatment if it was available for me," said Richard Martinez, 35, a psychologist in Austin, Texas, who nonetheless understands some of the public skepticism."I think it'd be naÃ¯ve to think that resources wouldn't get someone to the front of the line," he said.Britain's medical regulator warned Wednesday that people with a history of serious allergic reactions shouldn't get the erectile dysfunction treatment from Pfizer and BioNTech, and investigators looked into whether two reactions on the first day of the U.K.'s vaccination program were linked to the shot.The advice was issued on a "precautionary basis," and the people who had the reactions had recovered, said professor Stephen Powis, medical director for National Health Service in England.Pfizer and BioNTech said they were working with investigators "to better understand each case and its causes."Also on Wednesday, Canada's health regulator approved the treatment, with Dr. Supriya Sharma, chief medical adviser at Heath Canada, calling it "a momentous occasion."Canada is set to receive up to 249,000 doses this month and Canadian officials expect to start administering them next week as soon after they are shipped from Belgium on Friday.Britain's Medical and Healthcare Products can you take viagra if you have high blood pressure Regulatory Agency has said people should not receive the shot if they have had a significant allergic reaction to a treatment, medicine or food, such as those who have been told to carry an adrenaline shot â such as an EpiPen or other similar devices â or others who have had potentially fatal allergic reactions. The medical regulator also said vaccinations should can you take viagra if you have high blood pressure be carried out only in facilities that have resuscitation equipment. Such advice isn't uncommon.

Several treatments already on the market carry warnings about allergic reactions, and doctors know to watch for them when people who've had reactions to drugs or treatments in the past can you take viagra if you have high blood pressure are given new products.The two people who reported reactions were NHS staff members who had a history of significant allergies and carried adrenaline shots. Both had serious reactions but recovered after treatment, the can you take viagra if you have high blood pressure NHS said. Stephen Evans, a professor of pharmacoepidemiology at the London School of Hygiene &. Tropical Medicine, said the regulator can you take viagra if you have high blood pressure had done the right thing, but the general public shouldn't be worried about getting the treatment."For the general population, this does not mean that they would need to be anxious about receiving the vaccination. One has to remember that even things like Marmite can cause can you take viagra if you have high blood pressure unexpected severe allergic reactions," he said, referring to the food spread that is made from brewer's yeast.Dr.

Ashish Jha, dean of the school of public health at Brown University, said he would advise patients who have had severe allergic reactions to other medicines or foods to delay vaccination if they can while the two cases in the U.K. Are investigated can you take viagra if you have high blood pressure. He would extend that advice to people who carry EpiPens."The cautionary approach is to say to people who have had severe reactions to other things, 'just hold,'" Jha said, adding. "There is going to be a deep dive into these two people who got an allergic reaction" to the treatment.He added that because the treatment is so high-profile, "every little thing that happens all the time is can you take viagra if you have high blood pressure going to get magnified. We should can you take viagra if you have high blood pressure talk about it, we should be honest with people, but we should put it into context and help people understand ...

There is a small proportion of people who have an allergic reaction to almost any medicine."The comments came a day after Britain rolled out its mass vaccination program amid efforts to control a viagra that has killed more than 62,000 people across the country. The MHRA gave an emergency authorization to the Pfizer-BioNtech treatment last week, making Britain the first country to approve its widespread use.Even in nonemergency situations, health authorities must closely monitor new treatments and medications because studies in tens of can you take viagra if you have high blood pressure thousands of people can't detect a rare risk that would affect 1 in 1 million. Authorities have not said how many people have received the shot in Britain so far, but they plan can you take viagra if you have high blood pressure to give 800,000 doses in the first phase, which will target people over 80, nursing home staff and some NHS workers.Late-stage trials of the treatment found "no serious safety concerns," Pfizer and BioNTech said. More than 42,000 people have received two doses of the shot during those trials.Detailed data from the treatment's trials showed potential allergic reactions in 0.63% of those who received the treatment, compared with 0.51% of those who received the placebo. Reviewers from can you take viagra if you have high blood pressure the U.S.

Food and Drug Administration called this a "slight numerical imbalance."Documents published by the two companies showed that people with a history of severe allergic reactions were excluded from the trials, and doctors were advised to look can you take viagra if you have high blood pressure out for such reactions in trial participants who weren't previously known to have severe allergies.As part of its emergency authorization for the treatment, the MHRA required health care workers to report any adverse reactions to help regulators gather more information about safety and effectiveness.The agency is monitoring the treatment rollout closely and "will now investigate these cases in more detail to understand if the allergic reactions were linked to the treatment or were incidental," Powis said. "The fact that we know so soon about these two allergic reactions and that the regulator has acted on this to issue precautionary advice shows that this monitoring system is working well."Dr. June Raine, head of the medical regulatory agency, informed a parliamentary committee about the reactions during previously scheduled testimony on the viagra."We know from the very extensive clinical trials that this wasn't a can you take viagra if you have high blood pressure feature" of the treatment, she said. "But if we need to strengthen our advice, now that we have had this experience in the vulnerable populations, the groups who have been selected as a priority, we get that advice to the field immediately."Margaret Keenan, the first person to get the treatment in the U.K., was discharged Wednesday from University Hospital Coventry, where she had been undergoing a heart checkup when she was given the shot."I feel great and I'm so pleased to be able to go home and to spend some quality time with my family," the 90-year-old former shop clerk said in a statement released by the NHS..

As states frantically prepare to begin months of vaccinations that could end the viagra, a new poll finds only about half of Americans are ready to roll up their sleeves when their turn comes.The survey from The Associated Press-NORC Center for Public Affairs Research shows how to get prescribed viagra about a quarter of U.S. Adults aren't how to get prescribed viagra sure if they want to get vaccinated against the erectile dysfunction. Roughly another quarter say they won't.Many on the fence have safety concerns and want to watch how the initial rollout fares â skepticism that could hinder the campaign against the scourge that has killed nearly 290,000 Americans.

Experts estimate at least 70% how to get prescribed viagra of the U.S. Population needs to be vaccinated to achieve herd immunity, or the point at which enough people are protected how to get prescribed viagra that the viagra can be held in check."Trepidation is a good word. I have a little bit of trepidation towards it," said Kevin Buck, a 53-year-old former Marine from Eureka, California.

Buck said he and his family will probably get vaccinated eventually, if initial shots go well how to get prescribed viagra. "It seems like a little rushed, but I know there was absolutely a reason to rush it," he said of the treatment, which was developed with remarkable speed, less than a year after the viagra was identified how to get prescribed viagra. "I think a lot of people are not sure what to believe, and I'm one of them."Amid a frightening surge in erectile dysfunction treatment that promises a bleak winter across the country, the challenge for health authorities is to figure out what it will take to make people trust the shots that Dr.

Anthony Fauci, the top how to get prescribed viagra U.S. Infectious-disease expert, how to get prescribed viagra calls the light at the end of the tunnel."If Dr. Fauci says it's good, I will do it," said Mary Lang, 71, of Fremont, California.

She added how to get prescribed viagra. "Hopefully if enough of us get the treatment, we can make this viagra go away."Early data suggests the two U.S. Frontrunners -- how to get prescribed viagra one treatment made by Pfizer and BioNTech and another by Moderna and the National Institutes of Health -- offer strong protection.

The Food and Drug Administration is poring over study results to be sure the shots are safe before deciding in the coming days whether to allow mass vaccinations, as how to get prescribed viagra Britain began doing with Pfizer's shots on Tuesday.Despite the hopeful news, feelings haven't changed much from an AP-NORC poll in May, before it was clear a treatment would pan out.In the survey of 1,117 American adults conducted Dec. 3-7, about 3 in 10 said they are very or extremely confident that the first available treatments will have been properly tested for safety and effectiveness. About an equal how to get prescribed viagra number said they are not confident.

The rest fell somewhere how to get prescribed viagra in the middle. Experts have stressed that no corners were cut during development of the treatment, attributing the speedy work to billions in government funding and more than a decade of behind-the-scenes research.Among those who don't want to get vaccinated, about 3 in 10 said they aren't concerned about getting seriously ill from the erectile dysfunction, and around a quarter said the outbreak isn't as serious as some people say.About 7 in 10 of those who said they won't get vaccinated are concerned about side effects. Pfizer and Moderna how to get prescribed viagra say testing has uncovered no serious ones so far.

As with many treatments, recipients may experience fever, fatigue or sore arms from the injection, signs the immune system is revving up.But other risks might not crop up until treatments are more how to get prescribed viagra widely used. British health authorities are examining two possible allergic reactions on the first day the country began mass vaccinations with the Pfizer shot.Among Americans who won't get vaccinated, the poll found 43% are concerned the treatment itself could infect them â something that's scientifically impossible, since the shots don't contain any viagra. Protecting their family, their community and their own health are chief drivers how to get prescribed viagra for people who want the treatment.

Roughly three-quarters said life won't go back to normal until enough of the country is vaccinated."Even if it helps a little bit, how to get prescribed viagra I'd take it," said Ralph Martinez, 67, who manages a grocery store in Dallas. "I honestly think they wouldn't put something out there that would hurt us."Over the summer, about a third of Martinez's employees were out with erectile dysfunction treatment. He wears a mask daily but worries about the constant public contact and is concerned that his 87-year-old mother is similarly exposed running her business.erectile dysfunction treatment has killed or hospitalized Black, Hispanic and Native Americans how to get prescribed viagra at far higher rates than white Americans.

Yet 53% of white Americans said they will get vaccinated, compared with 24% of Black Americans and 34% of Hispanics like Martinez. Because of insufficient sample size, the survey could not analyze results among Native Americans or other racial and ethnic groups that make up how to get prescribed viagra a smaller proportion of the U.S. Population.Horace Carpenter of Davenport, Florida, knows that as a Black man how to get prescribed viagra at age 86, he is vulnerable.

"I'd like to see it come out first," he said of the treatment. But he said he, too, plans to follow how to get prescribed viagra Fauci's advice.Given the nation's long history of racial health care disparities and research abuses against Black people, Carpenter isn't surprised that minority communities are more hesitant about the new treatments."There is such racial inequality in our society," he said. "There's bound to be some hiccups."Health experts say it is not surprising that people have doubts how to get prescribed viagra because it will take time for the treatments' study results to become widely known."Sometimes you have to ask people more than once," said John Grabenstein of the Immunization Action Coalition, a retired Army colonel who directed the Defense Department's immunization program.

He said many eventually will decide it's "far, far better to take this treatment than run the risk of erectile dysfunction ."Adding to the challenge are political divisions that have hamstrung public health efforts to curtail the outbreak. The poll found 6 in how to get prescribed viagra 10 Democrats said they will get vaccinated compared with 4 in 10 Republicans. About a third of Republicans said they won't.Only about 1 in 5 Americans are very or extremely confident that how to get prescribed viagra treatments will be safely and quickly distributed, or fairly distributed, though majorities are at least somewhat confident.Nancy Nolan, 64, teaches English as a second language at a New Jersey community college and has seen the difficulty her students face in getting erectile dysfunction testing and care.

"I don't think it'll be fairly distributed," she said. "I hope I'm wrong." She raised concerns, too, over the speed with which the treatment how to get prescribed viagra was developed. "If I rush, I could have a car accident, I could make a mistake." Health workers and nursing home residents are set to be first in line for the scarce initial doses.

Plans call for other essential workers and people over how to get prescribed viagra 65 or at increased risk because of other health problems to follow, before enough treatment arrives for everyone, probably in the spring.The poll found majorities of Americans agree with that priority list. And 59% think vaccinating how to get prescribed viagra teachers should be a high priority, too. Most also agree with higher priority for hard-hit communities of color and people in crowded living conditions such as homeless shelters and college dorms."Once those individuals are cared for, I wouldn't hesitate to get the treatment if it was available for me," said Richard Martinez, 35, a psychologist in Austin, Texas, who nonetheless understands some of the public skepticism."I think it'd be naÃ¯ve to think that resources wouldn't get someone to the front of the line," he said.Britain's medical regulator warned Wednesday that people with a history of serious allergic reactions shouldn't get the erectile dysfunction treatment from Pfizer and BioNTech, and investigators looked into whether two reactions on the first day of the U.K.'s vaccination program were linked to the shot.The advice was issued on a "precautionary basis," and the people who had the reactions had recovered, said professor Stephen Powis, medical director for National Health Service in England.Pfizer and BioNTech said they were working with investigators "to better understand each case and its causes."Also on Wednesday, Canada's health regulator approved the treatment, with Dr.

Supriya Sharma, chief medical adviser at Heath Canada, calling it "a momentous occasion."Canada is set to receive up to 249,000 doses this month and Canadian officials expect to start administering them next week as soon after they are shipped how to get prescribed viagra from Belgium on Friday.Britain's Medical and Healthcare Products Regulatory Agency has said people should not receive the shot if they have had a significant allergic reaction to a treatment, medicine or food, such as those who have been told to carry an adrenaline shot â such as an EpiPen or other similar devices â or others who have had potentially fatal allergic reactions. The medical regulator also how to get prescribed viagra said vaccinations should be carried out only in facilities that have resuscitation equipment. Such advice isn't uncommon.

Several treatments already on the market carry warnings about allergic reactions, and doctors know to watch for them when people who've had reactions to drugs or treatments in the past are given new products.The two people who reported reactions were NHS staff members who had a history of significant allergies and carried adrenaline how to get prescribed viagra shots. Both had serious how to get prescribed viagra reactions but recovered after treatment, the NHS said. Stephen Evans, a professor of pharmacoepidemiology at the London School of Hygiene &.

Tropical Medicine, said the regulator had done the right thing, but the general public shouldn't be worried how to get prescribed viagra about getting the treatment."For the general population, this does not mean that they would need to be anxious about receiving the vaccination. One has to remember that even things like Marmite can cause unexpected severe allergic reactions," he said, referring to the food spread that is made from brewer's yeast.Dr how to get prescribed viagra. Ashish Jha, dean of the school of public health at Brown University, said he would advise patients who have had severe allergic reactions to other medicines or foods to delay vaccination if they can while the two cases in the U.K.

Are investigated how to get prescribed viagra. He would extend that advice to people who carry EpiPens."The cautionary approach is to say to people who have had severe reactions to other things, 'just hold,'" Jha said, adding. "There is going to be a deep how to get prescribed viagra dive into these two people who got an allergic reaction" to the treatment.He added that because the treatment is so high-profile, "every little thing that happens all the time is going to get magnified.

We should talk about it, we should be honest how to get prescribed viagra with people, but we should put it into context and help people understand ... There is a small proportion of people who have an allergic reaction to almost any medicine."The comments came a day after Britain rolled out its mass vaccination program amid efforts to control a viagra that has killed more than 62,000 people across the country. The MHRA gave an emergency authorization to the Pfizer-BioNtech treatment last week, making how to get prescribed viagra Britain the first country to approve its widespread use.Even in nonemergency situations, health authorities must closely monitor new treatments and medications because studies in tens of thousands of people can't detect a rare risk that would affect 1 in 1 million.

Authorities have not said how many people have received the shot in Britain how to get prescribed viagra so far, but they plan to give 800,000 doses in the first phase, which will target people over 80, nursing home staff and some NHS workers.Late-stage trials of the treatment found "no serious safety concerns," Pfizer and BioNTech said. More than 42,000 people have received two doses of the shot during those trials.Detailed data from the treatment's trials showed potential allergic reactions in 0.63% of those who received the treatment, compared with 0.51% of those who received the placebo. Reviewers from how to get prescribed viagra the U.S.

Food and Drug Administration called this a "slight numerical imbalance."Documents published by the two companies showed that people with a history of severe allergic reactions were excluded from the trials, and doctors were advised to look out for such reactions in trial participants who weren't previously known to have severe allergies.As part of its emergency authorization for the treatment, the MHRA required health care workers to report any adverse reactions to help regulators gather more how to get prescribed viagra information about safety and effectiveness.The agency is monitoring the treatment rollout closely and "will now investigate these cases in more detail to understand if the allergic reactions were linked to the treatment or were incidental," Powis said. "The fact that we know so soon about these two allergic reactions and that the regulator has acted on this to issue precautionary advice shows that this monitoring system is working well."Dr. June Raine, head of how to get prescribed viagra the medical regulatory agency, informed a parliamentary committee about the reactions during previously scheduled testimony on the viagra."We know from the very extensive clinical trials that this wasn't a feature" of the treatment, she said.

"But if we need to strengthen our advice, now that we have had this experience in the vulnerable populations, the groups who have been selected as a priority, we get that advice to the field immediately."Margaret Keenan, the first person to get the treatment in the U.K., was discharged Wednesday from University Hospital Coventry, where she had been undergoing a heart checkup when she was given the shot."I feel great and I'm so pleased to be able to go home and to spend some quality time with my family," the 90-year-old former shop clerk said in a statement released by the NHS..

Lisinopril and viagra

How to lisinopril and viagra cite this article:Singh OP. Mental health in diverse India. Need for lisinopril and viagra advocacy.

Indian J Psychiatry 2021;63:315-6âUnity in diversityâ - That is the theme of India which we are quite proud of. We have diversity in terms of geography â From the Himalayas to the deserts to the seas lisinopril and viagra. Every region has its own distinct culture and food.

There are so many varieties of dress and language. There is huge difference between the states in terms of development, attitude toward women, health lisinopril and viagra infrastructure, child mortality, and other sociodemographic development indexes. There is now ample evidence that sociocultural factors influence mental health.

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

The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed lisinopril and viagra northern states had more of childhood onset disorders.

This may be due to lead toxicity, nutritional status, and perinatal issues. Higher rates of depression and anxiety were found lisinopril and viagra in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms.

Marriage was found to be a negative prognostic indicator contrary lisinopril and viagra to the western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders. The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions.

Apart from culture bound syndromes, the role of cultural idioms lisinopril and viagra of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1â5 lakhs, it was 41,197, and in higher income group, it was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these require sustained advocacy lisinopril and viagra aimed at promoting rights of mentally ill persons and reducing stigma and discriminations.

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

There has been huge work done in this regard at institution level. Important research work done in this regard includes the National Mental Health Survey, National Survey on Extent and Pattern of Substance Use in India, Global Burden of Diseases lisinopril and viagra in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers.

Similarly, at organizational level, the Indian Psychiatric lisinopril and viagra Society (IPS) has filed a case for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from âMental Hai Kyaâ to âJudgemental Hai Kya.â In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality. The IPS has also started helplines at different levels and media interactions.

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

References 1.Compton MT, Shim RS. The social determinants of mental lisinopril and viagra health. Focus 2015;13:419-25.

2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al. National Mental Health Survey of India, 2015-16 lisinopril and viagra. Prevalence, Patterns and Outcomes.

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

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

The Global Burden of Disease Study 1990â2017. Lancet Psychiatry 2020;7:148-61. 4.National Crime Records Bureau, 2019.

Accidental Deaths and Suicides in India. 2019. Available from.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical assessments were done apart from detailed sexual history. The patients were 15â50 years of age, educated up to mid-school and mostly from a rural background. Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age.

There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16â23 years).

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

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

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

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

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

In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%â66.7%) were from rural areas, belonged to âconservative families and posed rigid views about sexâ (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class. Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss.

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%).

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

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

The average age of the patients was 23.53 years and it ranged between 15 and 68 years. The most affected age group of patients was of 18â25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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.

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

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.

How to visit their website cite this article:Singh OP how to get prescribed viagra. Mental health in diverse India. Need for advocacy how to get prescribed viagra. Indian J Psychiatry 2021;63:315-6âUnity in diversityâ - That is the theme of India which we are quite proud of. We have diversity in terms of geography â From the Himalayas to how to get prescribed viagra the deserts to the seas.

Every region has its own distinct culture and food. There are so many varieties of dress and language. There is huge difference how to get prescribed viagra between the states in terms of development, attitude toward women, health infrastructure, child mortality, and other sociodemographic development indexes. There is now ample evidence that sociocultural factors influence mental health. Compton and how to get prescribed viagra Shim[1] have described in their model of gene environment interaction how public policies and social norms act on the distribution of opportunity leading to social inequality, exclusion, poor environment, discrimination, and unemployment.

This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and early brain insult with low access to health care leads how to get prescribed viagra to poor mental health, disease, and morbidity.When we come to the field of mental health, we find huge differences between different states of India. The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of how to get prescribed viagra adult-onset disorders such as depression and anxiety, the less developed northern states had more of childhood onset disorders.

This may be due to lead toxicity, nutritional status, and perinatal issues. Higher rates of depression and anxiety were found how to get prescribed viagra in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms. Marriage was found to be a negative prognostic indicator contrary to the western how to get prescribed viagra norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders.

The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions. Apart from culture bound syndromes, the role of cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was how to get prescribed viagra 92,083, in annual income group of 1â5 lakhs, it was 41,197, and in higher income group, it was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these require sustained advocacy aimed at promoting rights of mentally ill persons and how to get prescribed viagra reducing stigma and discriminations. It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population.

Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and pathways should be to build technical evidence for mapping out the problem, cost-effective interventions, and their efficacy.Advocacy can be done at institutional how to get prescribed viagra level, organizational level, and individual level. There has been huge work done in this regard at institution level. Important research work done in this regard includes the National Mental Health Survey, National Survey on how to get prescribed viagra Extent and Pattern of Substance Use in India, Global Burden of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers.

Similarly, at organizational level, the Indian Psychiatric Society (IPS) has how to get prescribed viagra filed a case for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from âMental Hai Kyaâ to âJudgemental Hai Kya.â In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality. The IPS has also started helplines at different levels and media interactions. The Indian Journal of Psychiatry has also come out with editorials highlighting the how to get prescribed viagra need of care of marginalized population such as migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation.

When the enemy is economic inequality, our weapon is research highlighting the role of these factors on mental how to get prescribed viagra health. References 1.Compton MT, Shim RS. The social how to get prescribed viagra determinants of mental health. Focus 2015;13:419-25. 2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al.

National Mental Health Survey of how to get prescribed viagra India, 2015-16. Prevalence, Patterns and Outcomes. Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No. 129.

2016. 3.Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India. The Global Burden of Disease Study 1990â2017. Lancet Psychiatry 2020;7:148-61.

4.National Crime Records Bureau, 2019. Accidental Deaths and Suicides in India. 2019. Available from. Https://ncrb.gov.in.

[Last accessed on 2021 Jun 24]. 5.Machado DB, Rasella D, dos Santos DN. Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015;10:e0124934. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

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

Dhat syndrome (DS), the term coined by Dr. N. N. Wig, has been at the forefront of advancements in understanding and misunderstanding. The concept of DS is still evolving being treated as a culture-bound syndrome in the past to a syndrome of depression and treated as âa culturally determined idiom of distress.â It is bound with myths, fallacies, prejudices, secrecy, exaggeration, and value-laden judgments.

Although it has been reported from many countries, much of the literature has emanated from Asia, that too mainly from India. The research in India has ranged from the study of a few cases in the past to recent national multicentric studies concerning phenomenology and beliefs of patients. The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature.

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

Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS). Even though Dr. Wig is no more, his legacy of profound contribution to psychiatry and psychiatric education in general and service to the society and Mental Health, in particular, is well documented. His keen observation and study culminated in synthesizing many aspects and developments in DS.I would also like to place on record my humble pranams to my teachers from Christian Medical College, Vellore â Dr.

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

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

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

The most important debate is, however, related to the nosological status of DS. Although considered to a CBS unique to India, it has also been increasingly reported in China, Europe, Japan, Malaysia, Russia, and America.[11] The consistency and validity of its diagnosis have been consistently debated, and one of the most vital questions that emerged was. Can there be another way to conceptualize DS?. There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders.

Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue. Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively. Depression continued to be reported as the most common association of DS in many studies.[25],[26] This âcause-effectâ dilemma can never be fully resolved. Whether âloss of semenâ and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument. However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness.

Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management. He also mentions that the underlying âemotional distress and cultural contextsâ are not unique to DS but can be related to any psychiatric syndrome for that matter. On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of âmood disordersâ can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a âcultural phenotypeâ of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.

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

This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder. Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders. The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being. Most importantly, the multidimensional presentation of DS can at certain times be a facade overshadowing underlying neurotic disorders (anxiety, depression, somatoform, hypochondriasis, and phobias), obsessive-compulsive spectrum disorders and body dysmorphic disorders, delusional disorders, sexual disorders (premature ejaculation and erectile dysfunction) and infectious disorders (urinary tract s, sexually transmitted diseases), and even stress-related manifestations in otherwise healthy individuals.[4],[14],[15] This significant overlap of symptomatology, increased prevalence, and marked comorbidity make it all the more important for physicians to make sense out of the construct of DS.

That can facilitate prompt detection and management of DS in routine clinical practice.In an earlier review study, it was observed that few studies are undertaken to update the research works from published articles as an updated review, systemic review, world literature review, etc., on DS and its management approach.[29],[32],[33],[34],[35] The present paper attempts to compile the evidence till date on DS related to its nosology, critique, manifestations, and management plan. The various empirical studies on DS all over the world will be briefly discussed along with the implications and importance of the syndrome. The Construct of Dhat Syndrome. Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as âsemen loss syndromeâ by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with âsemen loss anxietyâ suffer from a myriad of psychosexual symptoms, which have been attributed to âloss of vital essence through semenâ (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale.

The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms. Most commonly associated symptoms were found as per score â¥1. This study reported several parameters such as the âsense of being unhealthyâ (99%), worry (99%), feeling âno improvement despite treatmentâ (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%). The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness.

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

38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years. Every participant reported excessive loss of semen and was preoccupied with it. The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss.

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

60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for âDhatâ items on BSI. The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness. This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire.

Nearly one-third of the patients were passing âDhatâ multiple times a week. Among them, nearly 60% passed almost a spoonful of âDhatâ each time during a loss. This work on sexual disorders reported that the passage of âDhatâ was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%). Mostly, the participants experienced passage of Dhat as ânight fallsâ (60.1%) and âwhile passing stoolsâ (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the âloss of Dhat.â The associated symptoms were depression, hopelessness, feeling low, decreased energy levels, weakness, and lack of pleasure.

Erectile problems and premature ejaculation were also present.Rao[17] in his first epidemiological study done in Karnataka, India, showed the prevalence rate of DS in general male population as 12.5%. It was found that 57.5% were suffering either from comorbid depression or anxiety disorders. The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban). One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction.

The psychosexual symptoms were found among 113 patients who had DS. The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%). In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice. The view of participants was that semen is very âprecious,â needs preservation, and masturbation is a malpractice. Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders.

Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively. The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments. About 66% of the patients met the DSM-IV diagnostic criteria of depression. They concluded that depression was a frequent comorbidity in DS patients.In a study by Perme et al.[37] from South India that included 32 DS patients, the control group consisted of 33 people from the same clinic without DS, depression, and anxiety.

The researchers followed the guidelines of Bhatia and Malik's for the assessment of primary complaints of semen loss through ânocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.â The assessment was done based on several indices, namely âSomatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.â Several complaints such as somatic complaints, hypochondriacal beliefs, and fatigue were observed to be significantly higher among patients with DS compared to the control group.A study conducted in South Hall (an industrial area in the borough of Middlesex, London) included Indian and Pakistani immigrants. Young men living separately from their wives reported promiscuity, some being infected with gonorrhea and syphilis. Like other studies, nocturnal emission, weakness, and impotency were the other reported complaints. Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia).

Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age. There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16â23 years). The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill.

It was assumed in the study that semen loss is considered synonymous to âloss of something preciousâ, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and âDhatâ in urine (40%) were the common complaints observed. Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache. More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia.

About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders). Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse. 67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%).

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

Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas. In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%â66.7%) were from rural areas, belonged to âconservative families and posed rigid views about sexâ (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class. Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss.

They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment. The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class.

Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%). The subjects were single or unmarried (51.0%) and married (46.7%). About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes. Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%).

About 45.80% of the study subjects were illiterates and very few had completed postgraduation. The subjects were both married and single. Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone. Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%).

Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16â20 years (34%) followed by 21â25 years (28%), greater than 30 years (26%), 26â30 years (10%), and 11â15 years (2%). Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively. Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine.

In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years. The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%). Priyadarshi and Verma[43] performed a study in 110 male patients with DS. The average age of the patients was 23.53 years and it ranged between 15 and 68 years.

The most affected age group of patients was of 18â25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years. Higher percentage of the patients were unmarried (70%). Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively.

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

Only a few patients received higher education. Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single. It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training. Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%).

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

The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals. Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone. Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality.

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

Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary. CBS like DS forms a major area of this nosological controversy. Longitudinal stability of a diagnosis is considered to be an important part of its independent categorization. Sameer et al.[23] followed up DS patients for 6.0 Â± 3.5 years and concluded that the âpureâ variety of DS is not a stable diagnostic entity.

The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right âplaceâ for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different. While ICD-10 considers DS under âother nonpsychotic mental disordersâ (F48), DSM-V mentions it only in appendix section as âcultural concepts of distressâ not assigning the condition any particular number.[12],[58] Fundamental questions have actually been raised about its separate existence altogether,[35] which further puts its diagnostic position in doubt. As discussed in the earlier sections, an alternate hypothesization of DS is a cultural variant of depression, rather than a âtrue syndrome.â[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural âidiomâ of distress in specific geographical regions or a manifestation of other primary psychiatric disorders.[59] Qualitative studies in doctors have led to marked discordance in their opinion about the validity and classificatory area of DS.[60] The upcoming ICD-11 targets to pay more importance to cultural contexts for a valid and reliable classification.

However, separating the phenomenological boundaries of diseases might lead to subsetting the cultural and contextual variants in broader rubrics.[61],[62] In that way, ICD-11 might propose alternate models for distinction of CBS like DS at nosological levels.[62] It is evident that various factors include socioeconomics, acceptability, and sustainability influence global classificatory systems, and this might influence the ânicheâ of DS in the near future. It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader ânarrativeâ of depression. In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric âconstructâ which is equally interesting and controversial. Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality.

Beyond the traditional debate about its âseparateâ existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health. It is also treatable, and hence, the detection, understanding, and awareness become vital to its management. This oration attempts a âbird's eyeâ view of this CBS taking into account a holistic perspective of the available evidence so far. The clinical manifestations, diagnostic and epidemiological attributes, management, and nosological controversies are highlighted to provide a comprehensive account of DS and its relevance to mental health. More systematic and mixed methods research are warranted to unravel the enigma of this controversial yet distressing psychiatric disorder.AcknowledgmentI sincerely thank Dr.

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10.4103/psychiatry.IndianJPsychiatry_791_20.