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A fourth wave of the opioid epidemic is coming, a national expert on drug use and policy said during a virtual panel discussion this week hosted by the Berkshire cheap cipro pills County, Massachusetts, District Attorney’s Office and the Berkshire Opioid Addiction Prevention Collaborative.Dr. Daniel Ciccarone, a professor of family and community medicine at the University of California, San Francisco (UCSF) School of Medicine, said the next wave in the country’s opioid health emergency will focus on stimulants like methamphetamine and cocaine, and drug combinations where stimulants are used in conjunction with opioids.“The use of methamphetamines is back and it’s back big time,” said Ciccarone, whose most recent research has focused on heroin use.Previously, officials had said there were three waves of the opioid epidemic – the first being prescription pills, the second being heroin, and the third being synthetic drugs, like fentanyl.Now, Ciccarone said, what federal law enforcement and medical experts are seeing is an increase in the use of stimulants, especially methamphetamines.The cheap cipro pills increase in deaths due to stimulants may be attributed to a number of causes. The increase in supply, both imported and domestically produced, as well as the increase of the drugs’ potency.“Meth’s purity and potency has gone up to historical levels,” he said.

€œAs of 2018, we’ve reached unseen heights of 97 percent potency and 97 percent cheap cipro pills purity. In a prohibitionist world, we should not be seeing such high quality. This is almost pharmaceutical quality.”Additionally, law enforcement and public health experts like Ciccarone are seeing an increase in the co-use of stimulants with opioids, he said cheap cipro pills.

Speedballs, cocaine mixed with heroin, and goofballs, methamphetamines used with heroin or fentanyl, are becoming more common from the Midwest into Appalachia and up through New England, he said.Federal law enforcement officials are recommending local communities prepare for the oncoming rise in illegal drugs coming into their communities.“Some people will use them both at the same time, but some may use them in some combination regularly,” he said. €œThey may use meth in the morning to go to work, and use heroin at night to come down.”The co-use, he said, cheap cipro pills was an organic response to the fentanyl overdose epidemic.“Some of the things that we heard … is that meth is popularly construed as helping to decrease heroin and fentanyl use. Helping with heroin withdraw symptoms and helping with heroin overdoses,” he said.

€œWe debated this for many years that people were using cheap cipro pills stimulants to reverse overdoses – we’re hearing it again.”“Supply is up, purity is up, price is down,” he said. €œWe know from economics that when drug patterns go in that direction, use is going up.”Ciccarone said that there should not be deaths because of stimulants, but that heroin/fentanyl is the deadly element in the equation.His recommendations to communities were not to panic, but to lower the stigma surrounding drug use in order to affect change. Additionally, he said, policies should focus cheap cipro pills on reduction.

supply reduction, demand reduction and harm reduction. But not cheap cipro pills focus on only one single drug.Additionally, he said that by addressing issues within communities and by healing communities socially, economically and spiritually, communities can begin to reduce demand.“We’ve got to fix the cracks in our society, because drugs fall into the cracks,” he said.Shutterstock U.S. Rep.

Annie Kuster (D-NH) recently held two virtual roundtables addressing how buy antibiotics has affected New Hampshire’s healthcare industry.“The health and cheap cipro pills economic crisis caused by buy antibiotics has created significant challenges for Granite State healthcare, mental health, and substance use treatment providers — at the same time, we are seeing increases in substance abuse and mental illness across New Hampshire,” Kuster said. €œFrom the transition to telehealth care and cancellations of elective procedures to a lack of personal protective equipment and cheap cipro pills increasing health needs of our communities – providers have overcome a multitude of obstacles due to buy antibiotics in recent months. I was glad to hear from these hard-working Granite Staters, whose insights will continue to guide my work in Congress as we respond to this cipro.

I’m committed to ensuring that communities across New Hampshire can safely access the care and treatment they deserve.”The first roundtable addressed substance-use disorder (SUD) and mental health.The second virtual roundtable was an opportunity for health care providers to speak about cheap cipro pills their workplace challenges during the cipro. Kuster is the founder and co-chairwoman of the Bipartisan Opioid Task Force, which held a virtual discussion in June on the opioid crisis and the cipro.Shutterstock Opioid prescription rates for outpatient knee surgery vary nationwide, according to a study recently published in BMJ Open. €œWe found massive levels of variation in the proportion of cheap cipro pills patients who are prescribed opioids between states, even after adjusting for nuances of the procedure and differences in patient characteristics,” said Dr.

M. Kit Delgado, the study’s senior author and an assistant professor of Emergency Medicine and Epidemiology in the Perelman cheap cipro pills School of Medicine at the University of Pennsylvania. €œWe’ve also seen that the average number of pills prescribed was extremely high for outpatient procedures of this type, particularly for patients who had not been taking opioids prior to surgery.”Researchers examined insurance claims for nearly 100,000 patients who had arthroscopic knee surgery between 2015 and 2019 and had not used any opioid prescriptions in the six months before the surgery.Within three days of a procedure, 72 percent of patients filled an opioid prescription.

High prescription rates cheap cipro pills were found in the Midwest and the Rocky Mountain regions. The coasts had lower rates.Nationwide, the average prescription strength was equivalent to 250 milligrams of morphine over five days. This is the threshold for increased risk of opioid overdose death, according to cheap cipro pills the Centers for Disease Control and Prevention.Shutterstock U.S.

Secretary of Labor Eugene Scalia awarded nearly $20 million to four states significantly impacted by the opioid crisis, the Department of Labor announced Thursday. The Florida Department of Economic cheap cipro pills Opportunity, the Maryland Department of Labor, the Ohio Department of Job and Family Services, and the Wisconsin Department of Workforce Development were awarded the money as part of the DOL’s “Support to Communities. Fostering Opioid Recovery through Workforce Development” created after the passage of the SUPPORT for Patients and Communities Act of 2018.

The money will be used to retrain workers in areas with high rates cheap cipro pills of substance use disorders. At a press conference in Piketon, Ohio, Scalia said the DOL had awarded Ohio’s Department of Job and cheap cipro pills Family Services $5 million to help communities in southern Ohio combat the opioid crisis in that area. €œToday’s funding represents this Administration’s continued commitment to serving those most in need,” said Assistant Secretary for Employment and Training John Pallasch.

€œThe U.S cheap cipro pills. Department of Labor is taking a strong stand to support individuals and communities impacted by the crisis.”Grantees will use the funds to collaborate with community partners, such as employers, local workforce development boards, treatment and recovery centers, law enforcement officials, faith-based community organizations, and others, to address the economic effects of substance misuse, opioid use, addiction, and overdose.Shutterstock CVS Health has completed the installation of time-delayed safe technology at all 446 Massachusetts locations as part of its initiatives aimed at reducing the misuse and diversion of prescription medications in Massachusetts, the company announced Thursday. The safes are intended to prevent robberies of controlled substance medications, such as oxycodone and hydrocodone, by electronically delaying the time it takes for pharmacy employees to open the safe where those drugs are stored.The company also announced that it had added 50 new medication disposal units in cheap cipro pills select stores throughout Massachusetts.

Those units join 106 secure disposal units previously installed at CVS locations across the state and another 43 units previously donated to Massachusetts law enforcement agencies. The company cheap cipro pills plans to install another six units in stores by the year’s end. €œWhile our nation and our company focus on buy antibiotics treatment, testing, and other measures to prevent community transmission of the cipro, the misuse of prescription drugs remains an ongoing challenge in Massachusetts and elsewhere that warrants our continued attention,” said John Hering, Region Director for CVS Health.

€œThese steps to reduce the theft and diversion of opioid medications bring added security to our stores and more disposal options for our communities.”In 2015, CVS implemented time-delayed safe technology in CVS pharmacies across Indianapolis in response to the high volume of pharmacy robberies in that cheap cipro pills city. The company saw a 70 percent decline in pharmacy robberies in stores where the time-delayed safes were installed. Since then, the company has installed 4,760 time-delayed safes in 15 states and the District of Columbia and cheap cipro pills has seen a 50 percent decline in pharmacy robberies in those areas.

The company said it would add an additional 1,000 in-store medication disposal units to the 2,500 units it currently has in CVS pharmacies nationwide. The units allow customers to cheap cipro pills drop unused prescriptions into a safe place for their disposal to prevent those drugs from being misused. CVS stores that do not offer medication disposal units offer all customers filling opioid prescriptions for the first time with DisposeRX packets that effectively and efficiently breakdown unused drugs into a biodegradable gel for safe disposal in the trash at home..

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Dropping dual antiplatelet therapy (DAPT) in favor of aspirin alone at 1 month after drug-eluting stent (DES) implantation for stable coronary disease patients was not worse than longer DAPT regimens, a trial suggested.The 1-year composite of cardiac death, nonfatal MI, target-vessel revascularization, cerebrovascular accident, or major bleeding occurred in 5.9% of people treated with the short DAPT regimen after getting the BioFreedom polymer-free DES compared with 6.5% of people who got 6 to 12 months of DAPT after getting a http://dripcolumbia.com/levitra-for-sale-in-canada/ durable-polymer BioMatrix or Ultimaster DES.That absolute 0.7% difference between what is cipro for groups met criteria for non-inferiority, reported Myeong-Ki Hong, MD, PhD, of Severance Cardiovascular Hospital in Seoul, South Korea, at the American Heart Association (AHA) virtual meeting.The same was true in a landmark analysis looking at events after 1 month and for all secondary endpoints.A subgroup analysis suggested that the short DAPT regimen might not be safe in patients who had presented with acute coronary syndrome (primary composite event rate 7.2% vs 5.1% with longer DAPT, HR 1.43, P=0.013 for interaction), albeit based on relatively few events in the 3,020-patient randomized trial.The multicenter, open-label trial included patients who presented for elective percutaneous coronary intervention (PCI) both with and without high bleeding risk. Acute MI, complex lesions, and cardiogenic shock were exclusion criteria.It's the first randomized trial to support the safety of a 1-month DAPT regimen after stenting low-risk patients, noted AHA session discussant Róisín Colleran, MB BCh, of the Cardiovascular Research Institute Dublin.Aspirin monotherapy is cheaper and has fewer off-target side effects than ticagrelor (Brilinta), as well as less variation in treatment response than clopidogrel what is cipro for (Plavix) for P2Y12 inhibitor monotherapy, she noted.However, none of the stents tested in the trial are approved for use in the U.S. Interpretation of the what is cipro for results was also complicated by the mix of stent types, with different strut thicknesses across the three used, and the range of longer DAPT used as a comparator, she added."It will be important now to see if this might be a class effect that can be extended to other more widely used stents in this country," commented B.

Hadley Wilson, what is cipro for MD, of Sanger Heart &. Vascular Institute-Charlotte in North Carolina and a spokesperson for the American College of Cardiology."Is it related to this being a polymer-free stent, or is it what is cipro for just the design of all these late-generation stents are so much better now that you can have shorter DAPT as a class effect?. " he posited in an interview with MedPage Today.Evidence is accruing for shorter DAPT regimens, what is cipro for as each stent would need safety data to provide the FDA to get an indication for it, which the Resolute Onyx drug eluting stent recently did for 1-month DAPT for high bleeding risk patients.However, the trend has been to drop aspirin rather than the more potent antiplatelet agent, noted Roxana Mehran, MD, of Icahn School of Medicine at Mount Sinai in New York City."At the moment we have a lot of data, especially with the LEADERS FREE evaluation in 1-month DAPT, as well as the ONYX ONE, and most recently on the Xience 28-days and 90-days evaluation...showing really really good results as far as the hard endpoints," she told MedPage Today.Hong and colleagues study was fairly small for looking at hard clinical endpoints, she added."I believe we are moving toward, if we're looking at stent-related complications in elective PCI for stable coronary disease, that we can go even shorter," she said.

However, "we shouldn't be so cavalier about applying these to every single patient," she argued, especially high-risk patients like smokers or those with diabetes, multivessel disease, or acute coronary syndrome.For such patients with low bleeding risk, "I still would like to give them either a dual antiplatelet therapy or a TWILIGHT type of strategy after PCI, which is ticagrelor monotherapy," she said.Longer duration antiplatelet use may have some benefit beyond just the stent-related complications, as suggested in the DAPT trial what is cipro for showing that an extended duration of DAPT for as much as 30 months after DES implantation held benefit. Disclosures Mehran disclosed relevant relationships with Applied Therapeutics, Claret Medical, Elixir Medical, STEL, ControlRad, Janssen Scientific Affairs, Boston Scientific, California Institute for Regenerative Medicine, Society for Cardiovascular what is cipro for Angiography and Interventions, American College of Cardiology, and American Medical Association.Colleran and Wilson disclosed no relevant relationships with industry..

Dropping dual antiplatelet therapy (DAPT) in favor of aspirin cheap cipro pills alone at 1 month after drug-eluting stent (DES) implantation for stable coronary disease patients was not worse than longer DAPT regimens, a trial suggested.The 1-year composite of cardiac death, nonfatal MI, target-vessel revascularization, cerebrovascular accident, or major bleeding occurred in 5.9% of people treated with the short DAPT regimen after getting the BioFreedom polymer-free DES compared with 6.5% of people who got 6 to 12 months of DAPT after getting a durable-polymer BioMatrix or Ultimaster DES.That absolute 0.7% difference between groups met criteria for non-inferiority, reported Myeong-Ki Hong, MD, PhD, of Severance Cardiovascular Hospital in Seoul, South Korea, at the American Heart Association (AHA) virtual meeting.The same was true in a landmark analysis looking at events after 1 month and for all secondary endpoints.A subgroup analysis suggested that the short DAPT regimen might not be safe in patients who had presented with acute coronary syndrome (primary http://dripcolumbia.com/levitra-for-sale-in-canada/ composite event rate 7.2% vs 5.1% with longer DAPT, HR 1.43, P=0.013 for interaction), albeit based on relatively few events in the 3,020-patient randomized trial.The multicenter, open-label trial included patients who presented for elective percutaneous coronary intervention (PCI) both with and without high bleeding risk. Acute MI, complex lesions, and cardiogenic shock were exclusion criteria.It's the first randomized trial to support the safety of a 1-month DAPT regimen after stenting low-risk patients, noted AHA session discussant Róisín Colleran, MB BCh, of the Cardiovascular Research Institute Dublin.Aspirin monotherapy is cheaper and has fewer off-target side effects than ticagrelor (Brilinta), as well as less variation in treatment response than clopidogrel (Plavix) for P2Y12 inhibitor monotherapy, she noted.However, none of the stents tested in the cheap cipro pills trial are approved for use in the U.S. Interpretation of the results was also complicated by the mix of stent types, with different strut thicknesses across the three used, and the range of longer DAPT used as a comparator, she added."It will be important now to see if this might be a class effect that can be extended to cheap cipro pills other more widely used stents in this country," commented B.

Hadley Wilson, MD, of Sanger cheap cipro pills Heart &. Vascular Institute-Charlotte in North Carolina and a spokesperson for the American College cheap cipro pills of Cardiology."Is it related to this being a polymer-free stent, or is it just the design of all these late-generation stents are so much better now that you can have shorter DAPT as a class effect?. " he posited in an interview with MedPage Today.Evidence is accruing for shorter DAPT regimens, as each stent would need safety data to provide the FDA to get an indication for it, which the Resolute Onyx drug eluting stent recently did for 1-month DAPT for high bleeding risk patients.However, the trend has been to drop aspirin rather than the more potent antiplatelet agent, noted Roxana Mehran, MD, of Icahn School of Medicine at Mount Sinai in New York City."At the moment we have a lot of data, especially with the LEADERS FREE evaluation in 1-month DAPT, as well as the ONYX ONE, and most recently on the Xience 28-days and 90-days evaluation...showing really really good results as far as the hard endpoints," cheap cipro pills she told MedPage Today.Hong and colleagues study was fairly small for looking at hard clinical endpoints, she added."I believe we are moving toward, if we're looking at stent-related complications in elective PCI for stable coronary disease, that we can go even shorter," she said.

However, "we shouldn't be so cavalier about applying these to every single patient," she argued, especially high-risk patients like smokers or cheap cipro pills those with diabetes, multivessel disease, or acute coronary syndrome.For such patients with low bleeding risk, "I still would like to give them either a dual antiplatelet therapy or a TWILIGHT type of strategy after PCI, which is ticagrelor monotherapy," she said.Longer duration antiplatelet use may have some benefit beyond just the stent-related complications, as suggested in the DAPT trial showing that an extended duration of DAPT for as much as 30 months after DES implantation held benefit. Disclosures Mehran disclosed relevant relationships with Applied Therapeutics, Claret Medical, Elixir Medical, STEL, ControlRad, Janssen Scientific Affairs, Boston Scientific, California Institute for Regenerative Medicine, Society cheap cipro pills for Cardiovascular Angiography and Interventions, American College of Cardiology, and American Medical Association.Colleran and Wilson disclosed no relevant relationships with industry..

What side effects may I notice from Cipro?

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

  • allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
  • breathing problems
  • confusion, nightmares or hallucinations
  • feeling faint or lightheaded, falls
  • irregular heartbeat
  • joint, muscle or tendon pain or swelling
  • pain or trouble passing urine
  • redness, blistering, peeling or loosening of the skin, including inside the mouth
  • seizure
  • unusual pain, numbness, tingling, or weakness

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

  • diarrhea
  • nausea or stomach upset
  • white patches or sores in the mouth

This list may not describe all possible side effects.

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Medical director, can i buy cipro online Pulmonary Rehabilitation Program, VA Connecticut Healthcare cipro used to treat System. Benjamin J. Seides, MD, director, interventional pulmonology, Northwestern Medicine Central DuPage Hospital. Merck Manual cipro used to treat. €œChronic Obstructive Pulmonary Disease (COPD),” “Treatment of Acute COPD Exacerbation.” American Lung Association.

€œCleaning Supplies http://karlaskreations.com/location/ and Household Chemicals,” “What You Need to Know About Your Wood-Burning Stove and Heater.” Chinese Medical Journal. €œAllergy and Chronic Obstructive Pulmonary Disease.” CDC. €œMold. Basic Facts about Mold and Dampness.” American Thoracic Society. €œHealth Problems and Burning Indoor Fuels.” EPA.

€œGuide to Air Cleaners in the Home.” California Air Resources Board.

Medical director, Pulmonary Rehabilitation Program, VA Connecticut cheap cipro pills Healthcare System. Benjamin J. Seides, MD, director, interventional pulmonology, Northwestern Medicine Central DuPage Hospital. Merck Manual cheap cipro pills.

€œChronic Obstructive Pulmonary Disease (COPD),” “Treatment of Acute COPD Exacerbation.” American Lung Association. €œCleaning Supplies and Household Chemicals,” “What You Need to Know About Your Wood-Burning Stove and Heater.” Chinese Medical Journal. €œAllergy and Chronic Obstructive Pulmonary Disease.” CDC. €œMold.

Basic Facts about Mold and Dampness.” American Thoracic Society. €œHealth Problems and Burning Indoor Fuels.” EPA. €œGuide to Air Cleaners in the Home.” California Air Resources Board.

Cipro medication

Latest Depression News THURSDAY, Nov cipro medication. 12, 2020 (HealthDay News)Women who struggle with mental health problems will sometimes forgo the most effective forms of birth control because of concerns about worsening those issues, but a new study delivers a reassuring cipro medication finding. The pill and other forms of hormonal birth control do not raise depression risk."This is a very common concern," explained senior study author Dr.

Jessica Kiley, chief of general obstetrics and gynecology at Northwestern University Feinberg School of Medicine, in Chicago."For some patients with anxiety disorders, when you discuss a contraceptive's potential cipro medication side effect, they get very worried. We're hoping to encourage women to focus on their contraceptive needs and cipro medication learn about options that are unlikely to cause depression," Kiley said.The hormonal contraceptives the study authors discussed include birth control pills, IUDs (intrauterine devices) and vaginal rings.The study, which was published online Nov. 10 in the American Journal of Psychiatry, is a comprehensive review of published research of birth control methods for women with psychiatric disorders.According to corresponding author Dr.

Katherine Wisner, professor of psychiatry cipro medication and behavioral sciences and obstetrics &. Gynecology at Northwestern, "When you review the entirety of the literature and ask, 'Do hormonal contraceptives cause cipro medication depression?. ,' the answer is definitely no." Wisner is also director of the Asher Center for the Study and Treatment of Depressive Disorders.Clinical studies and trials of women with psychiatric disorders have found similar rates of mood symptoms in women regardless of whether they were using hormonal contraceptives or not.

In some cases, the contraceptives may even stabilize the mood symptoms of women with psychiatric disorders, the study authors said.And the physical and mental stress of an unintended pregnancy could trigger a new and cipro medication recurrent bout of depression, including postpartum depression, Wisner added.The review authors hope the findings will lead to more collaboration between gynecologists and psychiatrists, who can work together to help their mutual patients. Psychiatrists don't cipro medication typically receive enough training on contraceptives to properly counsel women on their birth control choices, according to the report. And women also should be screened for depression at routine gynecological appointments, Wisner said."Women should know they always have access to many types of birth control, regardless of their history or likelihood of mental illness," Wisner said.

"They shouldn't feel like they're out there flailing on how to not get pregnant."It is important to get a baseline sense of a woman's cipro medication mental health before contraceptive use, so her psychiatrist can monitor her symptoms after starting it, Wisner added. This is especially critical for women with bipolar disorder, who have mood fluctuations cipro medication around their menstrual cycle, she explained in a university news release.Although interactions between psychiatric drugs and contraceptives are infrequent, doctors do need to be aware of important exceptions, Wisner said.Those exceptions include the antipsychotic clozapine and the bipolar/seizure drug carbamazepine, which can sometimes interfere with certain contraceptives, Wisner said. Natural compounds such as St.

John's Wort cipro medication may also decrease the effectiveness of hormonal contraceptives. SLIDESHOW Sex-Drive Killers cipro medication. The Causes of Low Libido See SlideshowLatest Cancer News By Amy Norton HealthDay ReporterTHURSDAY, Nov.

12, 2020 (HealthDay News)Lung cancer patients who harbor certain bacteria in the airways cipro medication may have a poorer prognosis, a new study finds, adding to evidence that the body's "microbiome" may play a role in cancer patients' outlook.The microbiome refers to the trillions of bacteria and other microbes that naturally dwell in the body. Research in cipro medication recent years has been revealing how important those bugs are to the body's normal functions, including immune system defenses.When it comes to cancer, studies have hinted that the microbiome can influence tumor progression, and patients' likelihood of responding to certain treatments.For example, a number of cancers can be treated with immunotherapy -- various approaches to boosting the immune system's natural tumor-fighting capacity. Research has found that patients who respond well to immunotherapies tend to have a different makeup in the gut microbiome, compared to patients who do not respond.The new study, published Nov.

11 in Cancer Discovery, took a different view cipro medication. Instead of focusing on the gut microbiome, researchers analyzed lung microbes of patients cipro medication with newly diagnosed lung cancer.In microbiome research, "the lung has really been ignored," said lead researcher Dr. Leopoldo Segal, director of the Lung Microbiome Program and an associate professor at New York University Grossman School of Medicine in New York City.Traditionally, he explained, the lungs were believed to be "sterile." But recent research has shown that even in healthy people, the lungs can harbor low amounts of bacteria -- drawn in from the air or the mouth.Segal's team wanted to see whether lung bacteria corresponded to lung cancer patients' prognosis.Looking at tissue samples from 83 patients, the researchers found that those with advanced-stage cancer carried more microbes than patients in the early stage of disease.And when patients did have "enrichment" with certain bacteria types, their odds of survival were lower -- even those with earlier-stage cancer.Specifically, patients harboring Veillonella, Prevotella and Streptococcus bacteria had a worse prognosis.

They also showed signs of an inflammatory immune response that, based on past research, may worsen lung cipro medication cancer patients' outlook.None of that proves the bacteria, themselves, were to blame, Segal said. The cancer itself might make the lungs more "receptive" to being colonized with bacteria.So the researchers turned to lab cipro medication mice. They transferred Veillonella bacteria into mice with lung cancer and found that the microbes revved up "bad" inflammation, fed tumor growth and shortened the animals' survival.That suggests lung bacteria might modulate the immune response in a way that affects lung cancer progression, according to Segal.But the microbiome is complicated, and it's hard to draw conclusions from mouse findings, according to Dr.

Thomas Marron of Mount Sinai's Tisch Cancer Institute in cipro medication New York City.Right now, he said, there is a "huge interest" in understanding the microbiome's influence in cancer."Studies like this are really interesting," said Marron, who was not involved with the research, "but we're probably a few decades away from being able to alter the microbiome to treat cancer."Individuals vary in their microbiome makeup, and that's determined by things like genetics and the immune system, Marron explained. So even if the body's microbial communities directly affect cancer prognosis, he said, it will be a long time before researchers can turn that into therapy."We still don't know cipro medication how we could effectively target the microbiome," Marron said.He pointed to one question from the new findings. Is there any link between the lung microbiome and patients' likelihood of responding to immunotherapy?.

Segal said his team plans cipro medication to study that.Dr. John Heymach cipro medication chairs thoracic/head and neck medical oncology at M.D. Anderson Cancer Center in Houston.

He called the findings "a compelling starting point," but also emphasized the long research road ahead."At this cipro medication point, we're not ready to directly act on this in the clinic, by either trying to kill 'bad' bacteria, or add back 'good' bacteria," said Heymach, who was not part of the study.So far, he noted, studies have reached different conclusions as to exactly which types of bacteria are related to better cancer outcomes -- which might be due to differences in how studies look for the microbes.And like Marron, Heymach pointed to the microbiome's complexity. It generally differs from cipro medication one large population to the next and among individuals -- based on numerous factors. QUESTION Lung cancer is a disease in which lung cells grow abnormally in an uncontrolled way.

See Answer Still, Heymach said the recent cipro medication "explosion" in microbiome research could eventually lead to applications in cancer treatment. Besides the possibility of altering the microbiome, he said doctors might be able to use patients' microbiome makeup as a cipro medication "biomarker" of their risk of progression.More informationThe American Cancer Society has more on cancer immunotherapy.SOURCES. Leopoldo Segal, M.D., M.S., director, Lung Microbiome Program, and associate professor, medicine, New York University Grossman School of Medicine, New York City.

John Heymach, M.D., Ph.D., chair, thoracic/head and neck medical oncology, University of Texas M.D cipro medication. Anderson Cancer Center, cipro medication Houston. Thomas Marron, M.D., Ph.D., assistant director, Early Phase and Immunotherapy Trials, Tisch Cancer Institute at Mount Sinai, New York City.

Cancer Discovery, cipro medication online, Nov. 11, 2020Copyright cipro medication © 2020 HealthDay. All rights reserved.

From Cancer Resources Featured Centers Health Solutions From Our cipro medication SponsorsLatest Men's Health News By Steven Reinberg HealthDay ReporterTHURSDAY, Nov. 12, 2020 (HealthDay News)Young men who consider using the drug Propecia to prevent baldness may be putting themselves at risk for depression and suicide, a new study suggests.Information from the World cipro medication Health Organization indicates that over the past 10 years, reports of suicidal ideation among young men using the drug have increased, rising significantly after 2012, the researchers said."There are many possible explanations for our findings," said senior researcher Dr. Quoc-Dien Trinh, from the division of urologic surgery at Brigham and Women's Hospital, in Boston.Either there is some sort of biological explanation linking Propecia (finasteride) to suicidality and psychological adverse events, or media attention, which heightened awareness and may have increased reporting of adverse events, may have played a role, he said."Patients should be made aware of this potential side effect and speak to their prescribing doctor if they have concerns," Trinh said.Finasteride was developed to shrink enlarged prostates, a condition called benign prostatic hyperplasia.

Its use was later extended to treat male-pattern baldness.Trinh's team used data from VigiBase, which gathers information from 153 countries on all adverse drug reactions and contains more than 20 million cipro medication safety reports.The researchers found 356 reports of suicidality and nearly 3,000 reports of other psychological problems among people taking finasteride.Most of these reports for suicidal ideation, depression and anxiety were among men taking finasteride for hair loss who were 45 and younger.These findings were not seen in older patients taking the drug for enlarged prostate glands.According to Dr. Michael Irwig, from the division of endocrinology at Beth Israel Deaconess Medical Center, in Boston, "The difference between finasteride in younger men versus older men is likely related to the severe toll this medication can take on younger men who develop persistent sexual side effects."A dramatic loss in sexual function in a younger man can lead to significant dating and relationship difficulties, which is less likely to be an issue in older men who may already have sexual dysfunction due to aging and who are already in a stable relationship, he noted."Sexual dysfunction in younger men can result in depression and, in a subset of these men, suicidal ideation," Irwig said.Trinh said that these findings should not be over-interpreted to say that finasteride causes suicides, only that there seems to be an association.He thinks, however, that many more young men taking finasteride contemplate suicide than reported to VigiBase.Abdulmaged Traish, a professor emeritus of urology at Boston University School of Medicine, believes that finasteride has a biological effect that disrupts the central nervous system in some young patients, which can have psychological effects like depression cipro medication and suicide.The drug can help some people, he said. "But it comes with a high price, especially for a nonthreatening disorder like alopecia [hair loss]," he noted.

"It's not a disease that kills people."If a man wants to try finasteride for hair loss, he should at least be told of the risks, Traish said."Physicians should have a frank, open discussion with the patient about the cipro medication potential adverse side effects of the drug," he said. "If the patient still wants to take it, it's OK, but at least tell him, honestly, this is what we know."Traish also thinks that the U.S cipro medication. Food and Drug Administration should have a "boxed warning" that the drug may cause suicide ideation in some young men.

No such warning is on the package insert cipro medication now.The report was published online Nov. 11 in cipro medication JAMA Dermatology.More information QUESTION It is normal to lose 100-150 hairs per day. See Answer For more on depression in men, head to the National Institute of Mental Health.SOURCES.

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

JAMA Dermatology, cipro medication Nov. 11, 2020, onlineCopyright © 2020 HealthDay. All rights cipro medication reserved.

From Healthy Resources Featured Centers cipro medication Health Solutions From Our SponsorsLatest Depression News FRIDAY, Nov. 13, 2020The antidepressant drug fluvoxamine -- best known by the brand name Luvox -- may help prevent serious illness in buy antibiotics patients who aren't yet hospitalized, a new study finds.The study included 152 patients infected with mild-to-moderate buy antibiotics. Of those, 80 took fluvoxamine and 72 took a placebo for 15 days.By the end of that time, none of the patients who took the drug had seen cipro medication their progress to serious illness, compared with six (8.3%) of the patients who took the placebo, according to researchers at Washington University School of Medicine in St.

Louis."The patients who took fluvoxamine did not develop serious breathing difficulties or require hospitalization cipro medication for problems with lung function," said first author Dr. Eric Lenze, professor of psychiatry."Most investigational treatments for buy antibiotics have been aimed at the very sickest patients, but it's also important to find therapies that prevent patients from getting sick enough to require supplemental oxygen or to have to go to the hospital. Our study suggests fluvoxamine may help fill that niche," Lenze noted in a university news release.Fluvoxamine -- widely used to treat depression, obsessive-compulsive disorder and cipro medication social anxiety disorder -- is a type of drug called a selective serotonin-reuptake inhibitor (SSRI).

This class of drugs also cipro medication includes medicines such as Prozac, Zoloft and Celexa.But unlike other SSRIs, fluvoxamine has a strong interaction with a protein called the sigma-1 receptor, which helps regulate the body's inflammatory response."There are several ways this drug might work to help buy antibiotics patients, but we think it most likely may be interacting with the sigma-1 receptor to reduce the production of inflammatory molecules," explained study senior author Dr. Angela Reiersen, associate professor of psychiatry."Past research has demonstrated that fluvoxamine can reduce inflammation in animal models of sepsis, and it may be doing something similar in our patients," she said in the release.By reducing inflammation, fluvoxamine may prevent a hyperactive immune response in buy antibiotics patients. That, in turn, may decrease their risk of serious illness and death, Reiersen said."Our goal is to help patients who are initially cipro medication well enough to be at home and to prevent them from getting sick enough to be hospitalized," Dr.

Caline Mattar, assistant professor of medicine in the Division of Infectious Diseases, said in the release cipro medication. "What we've seen so far suggests that fluvoxamine may be an important tool in achieving that goal."Dr. Amesh Adalja is a senior scholar at the Johns Hopkins Center cipro medication for Health Security in Baltimore.

He wasn't involved in the study, but said the research is "notable not only because of its positive outcome -- cipro medication we desperately need a medication that keeps buy antibiotics patients out of the hospital -- but also because of the manner in which it was conducted."But Adalja stressed that a larger trial is needed "to see if the promising findings hold up."The researchers said they plan to begin such a study in the next few weeks and it will include patients from across the United States.The preliminary study was published online Nov. 12 in the Journal of the American Medical Association.More informationFor more on buy antibiotics, go to the U.S. Centers for Disease cipro medication Control and Prevention.SOURCES.

Amesh Adalja, M.D., cipro medication senior scholar, Johns Hopkins Center for Health Security, Baltimore. Washington University in St. Louis, news cipro medication release, Nov.

12, 2020Ernie MundellCopyright © 2020 cipro medication HealthDay. All rights reserved. SLIDESHOW cipro medication Learn to Spot Depression.

Symptoms, Warning Signs, Medication See SlideshowLatest antibiotics News By Dennis Thompson HealthDay cipro medication ReporterTHURSDAY, Nov. 12, 2020 (HealthDay News)Early buy antibiotics treatment trial results announced by Pfizer this week caused hopes to soar for a swift end to the cipro that has killed more than 242,000 and infected more than 10 million in the United States alone.But even if the preliminary results released Monday pan out, it will still take many months to produce enough of the treatment to inoculate everyone in the United States, experts warn.The health care industry will also face special distribution challenges related to this particular treatment, which must be maintained in extremely cold storage and delivered in a two-shot regimen."People should be enthusiastic, but realize that the benefits that we get from that treatment are not going to be in the winter, they're not going to be now, in the short range. They're going to be going forward, likely in the spring to cipro medication summer of 2021," said Dr.

Amesh Adalja, a senior scholar with the Johns Hopkins Center for Health Security, in Baltimore."It shouldn't change your approach to the cipro medication cipro today, tomorrow, next week, next month," he added. "We are entering a period of the year where we're seeing intensification of spread all over the country. We need to cipro medication be very vigilant.

The cases cipro medication are getting to the point where they are inundating hospitals in some states. The trajectory of the cipro right now looks very bad for the winter."Adalja's words echo those of President-elect Joe Biden, who lauded news of Pfizer's treatment success but asked Americans to stay vigilant."America is still losing over 1,000 people a day from buy antibiotics, and that number is rising -- and will continue to get worse unless we make progress on masking and other immediate actions," Biden said on Monday. "That is cipro medication the reality for now, and for the next few months.

Today's announcement promises the chance to change that next year, but the tasks before us cipro medication now remain the same."'No serious safety concerns'The early information from Pfizer -- more than 90% effective -- is extremely encouraging, said Dr. Thad Stappenbeck, head of the Lerner Research Institute at the Cleveland Clinic, in Ohio."It means if you get the treatment, based on their early statistics you have a 90% chance if you encounter the cipro of not being infected, which is remarkable," Stappenbeck said. Pfizer had set a goal of 50% effectiveness for its treatment -- the average effectiveness of the annual flu shot.Of more than 43,500 people who got either the treatment or a placebo, there have been 94 confirmed cases of buy antibiotics, Pfizer said in its early analysis."Nearly all of the new s were in the placebo group," Stappenbeck said.Pfizer needs to spend a few more weeks collecting safety data before it can apply for an emergency cipro medication use authorization from the U.S.

Food and Drug Administration, but Stappenbeck expressed confidence that the treatment would prove safe."They've now gone from just a few dozen people or a few hundred people now to tens of thousands of people, and no serious safety concerns," he said.Pfizer aims to produce up to 50 million doses of the treatment by year's end -- enough to inoculate 25 million people -- and up to 1.3 billion doses in 2021.Pfizer is making the treatment at facilities in Kalamazoo, Mich., and Puurs, Belgium, according to The New York Times cipro medication. Doses distributed in the United States will mostly come from Kalamazoo.The U.S. Government has placed an initial order for 100 million doses of the treatment, at a cost of $1.95 billion, with an option to buy another 500 million doses, Politico reports."There's a goal of 660 million doses, so there's two doses for everyone in the United States that wants one," said Anna Legreid Dopp, senior director of clinical guidelines and quality improvement with the American Society of Health-System Pharmacists (ASHP), in Bethesda, Md.Who's cipro medication first in line?.

The early cipro medication doses likely will be given to health care workers and first responders, Dopp said, followed by people at high risk for severe buy antibiotics s.But distributing the doses across the country is expected to be a challenge in and of itself.The treatment has to be stored at around minus 94 degrees Fahrenheit, which is about as cold as it gets at the South Pole on a winter's day. The shot can withstand normal refrigeration only for about 24 hours, and room temperature for no more than two hours after thawing, Politico reports.Creating a "cold chain" of distribution that will keep the treatment frozen until it's time for a person's shot "absolutely is going to be an added burden," Adalja said."This doesn't just need to be kept at ordinary refrigerator temperatures. It needs to be kept at minus 70, minus 80 Centigrade, which is not something that most places have the ability to do no matter where you are in the United States, let alone the developing cipro medication world," Adalja said.These sorts of freezers are common at academic centers, and might even be found at community hospitals, Stappenbeck said.

"These are not super cipro medication expensive. They're $5,000 or $6,000," he added.Major shipping companies United Parcel Service (UPS) and FedEx are scrambling to build freezer farms in major hub cities across the nation, according to The New York Times. Airplanes and trucks also will need to be fitted with freezers.Dopp said other innovations cipro medication are in the works, such as "thermal suitcases that allow some flexibility if you don't have access to a freezer."Two-dose regimenThe other distribution problem that must be solved is timing.

People need to get the treatment in two doses, separated by about a month, Dopp said.Hospitals, doctors and pharmacies will need to set up computer systems to track patients and make sure cipro medication they get their second dose in a timely fashion, Dopp said. Otherwise, they won't get full protection from the treatment, and perhaps none at all.One other concern, 10 other buy antibiotics treatment candidates are in the final stages of testing, Dopp noted. As they get approved, doctors will need to track which patients have received which treatment."A patient can't get one treatment for their first dose and a different treatment from a different manufacturer for their second dose," she said.ASHP was concerned that as hospitals begin handing out the first shots, they would need to keep at least half their initial allotments in reserve so people could get cipro medication their second shot on time."The answer we received from the U.S.

Centers for Disease Control and Prevention is that they do not, that they will work to provide just-in-time second doses, which I think is encouraging because it does allow for more people to start cipro medication on their series," Dopp said.More informationLearn more about Pfizer's treatment.SOURCES. Amesh Adalja, MD, senior scholar, Johns Hopkins Center for Health Security, Baltimore. Thad Stappenbeck, MD, PhD, chair, Lerner Research Institute, Cleveland Clinic, Ohio.

Anna Legreid Dopp, PharmD, senior director, clinical guidelines and quality improvement, American Society of Health-System Pharmacists, Bethesda, Md.. The New York Times. PoliticoCopyright © 2020 HealthDay.

Latest Depression cheap cipro pills What do you need to buy propecia News THURSDAY, Nov. 12, 2020 (HealthDay News)Women who struggle with mental health problems will sometimes forgo the most effective forms of birth control because of concerns about worsening those issues, but a new study delivers a reassuring finding cheap cipro pills. The pill and other forms of hormonal birth control do not raise depression risk."This is a very common concern," explained senior study author Dr. Jessica Kiley, cheap cipro pills chief of general obstetrics and gynecology at Northwestern University Feinberg School of Medicine, in Chicago."For some patients with anxiety disorders, when you discuss a contraceptive's potential side effect, they get very worried.

We're hoping to encourage women to focus on their contraceptive needs and learn about options that are unlikely to cause depression," Kiley said.The hormonal contraceptives the cheap cipro pills study authors discussed include birth control pills, IUDs (intrauterine devices) and vaginal rings.The study, which was published online Nov. 10 in the American Journal of Psychiatry, is a comprehensive review of published research of birth control methods for women with psychiatric disorders.According to corresponding author Dr. Katherine Wisner, cheap cipro pills professor of psychiatry and behavioral sciences and obstetrics &. Gynecology at Northwestern, "When you review the entirety of the literature and ask, cheap cipro pills 'Do hormonal contraceptives cause depression?.

,' the answer is definitely no." Wisner is also director of the Asher Center for the Study and Treatment of Depressive Disorders.Clinical studies and trials of women with psychiatric disorders have found similar rates of mood symptoms in women regardless of whether they were using hormonal contraceptives or not. In some cases, the contraceptives cheap cipro pills may even stabilize the mood symptoms of women with psychiatric disorders, the study authors said.And the physical and mental stress of an unintended pregnancy could trigger a new and recurrent bout of depression, including postpartum depression, Wisner added.The review authors hope the findings will lead to more collaboration between gynecologists and psychiatrists, who can work together to help their mutual patients. Psychiatrists don't typically receive enough training on contraceptives to properly counsel women on their birth control choices, according to the report cheap cipro pills. And women also should be screened for depression at routine gynecological appointments, Wisner said."Women should know they always have access to many types of birth control, regardless of their history or likelihood of mental illness," Wisner said.

"They shouldn't feel like they're out there flailing on how to not get pregnant."It is important to get a baseline sense of a woman's mental health before contraceptive use, so her psychiatrist cheap cipro pills can monitor her symptoms after starting it, Wisner added. This is cheap cipro pills especially critical for women with bipolar disorder, who have mood fluctuations around their menstrual cycle, she explained in a university news release.Although interactions between psychiatric drugs and contraceptives are infrequent, doctors do need to be aware of important exceptions, Wisner said.Those exceptions include the antipsychotic clozapine and the bipolar/seizure drug carbamazepine, which can sometimes interfere with certain contraceptives, Wisner said. Natural compounds such as St. John's Wort may cheap cipro pills also decrease the effectiveness of hormonal contraceptives.

SLIDESHOW Sex-Drive cheap cipro pills Killers. The Causes of Low Libido See SlideshowLatest Cancer News By Amy Norton HealthDay ReporterTHURSDAY, Nov. 12, 2020 (HealthDay News)Lung cheap cipro pills cancer patients who harbor certain bacteria in the airways may have a poorer prognosis, a new study finds, adding to evidence that the body's "microbiome" may play a role in cancer patients' outlook.The microbiome refers to the trillions of bacteria and other microbes that naturally dwell in the body. Research in recent years has been revealing how important those bugs are to cheap cipro pills the body's normal functions, including immune system defenses.When it comes to cancer, studies have hinted that the microbiome can influence tumor progression, and patients' likelihood of responding to certain treatments.For example, a number of cancers can be treated with immunotherapy -- various approaches to boosting the immune system's natural tumor-fighting capacity.

Research has found that patients who respond well to immunotherapies tend to have a different makeup in the gut microbiome, compared to patients who do not respond.The new study, published Nov. 11 in Cancer Discovery, took a cheap cipro pills different view. Instead of focusing on the gut microbiome, researchers analyzed lung microbes of patients with newly diagnosed lung cancer.In microbiome research, "the lung has cheap cipro pills really been ignored," said lead researcher Dr. Leopoldo Segal, director of the Lung Microbiome Program and an associate professor at New York University Grossman School of Medicine in New York City.Traditionally, he explained, the lungs were believed to be "sterile." But recent research has shown that even in healthy people, the lungs can harbor low amounts of bacteria -- drawn in from the air or the mouth.Segal's team wanted to see whether lung bacteria corresponded to lung cancer patients' prognosis.Looking at tissue samples from 83 patients, the researchers found that those with advanced-stage cancer carried more microbes than patients in the early stage of disease.And when patients did have "enrichment" with certain bacteria types, their odds of survival were lower -- even those with earlier-stage cancer.Specifically, patients harboring Veillonella, Prevotella and Streptococcus bacteria had a worse prognosis.

They also showed signs of an inflammatory immune response that, based on past research, may worsen lung cancer patients' outlook.None cheap cipro pills of that proves the bacteria, themselves, were to blame, Segal said. The cancer itself might make the lungs more "receptive" cheap cipro pills to being colonized with bacteria.So the researchers turned to lab mice. They transferred Veillonella bacteria into mice with lung cancer and found that the microbes revved up "bad" inflammation, fed tumor growth and shortened the animals' survival.That suggests lung bacteria might modulate the immune response in a way that affects lung cancer progression, according to Segal.But the microbiome is complicated, and it's hard to draw conclusions from mouse findings, according to Dr. Thomas Marron of Mount Sinai's Tisch Cancer Institute in New York City.Right now, he said, there is a "huge interest" in understanding the microbiome's influence in cancer."Studies like this are really interesting," said Marron, who was not involved with the research, "but we're probably a few decades away from being cheap cipro pills able to alter the microbiome to treat cancer."Individuals vary in their microbiome makeup, and that's determined by things like genetics and the immune system, Marron explained.

So even if the body's microbial communities directly affect cancer prognosis, he said, it will be a long time before researchers can turn that into therapy."We still don't know how we could effectively target the microbiome," Marron said.He pointed to one cheap cipro pills question from the new findings. Is there any link between the lung microbiome and patients' likelihood of responding to immunotherapy?. Segal said cheap cipro pills his team plans to study that.Dr. John Heymach chairs thoracic/head and neck cheap cipro pills medical oncology at M.D.

Anderson Cancer Center in Houston. He called the findings "a compelling starting point," but also emphasized the long research road ahead."At this point, we're not ready to directly act on this in the clinic, by either trying to kill 'bad' bacteria, or add back 'good' bacteria," said Heymach, who was not part of the study.So far, he noted, studies have reached different conclusions as to exactly which types of bacteria are related to better cancer outcomes -- which might be due to differences in cheap cipro pills how studies look for the microbes.And like Marron, Heymach pointed to the microbiome's complexity. It generally differs from one large population to the next cheap cipro pills and among individuals -- based on numerous factors. QUESTION Lung cancer is a disease in which lung cells grow abnormally in an uncontrolled way.

See Answer Still, Heymach said the recent "explosion" in microbiome research could eventually lead to applications in cancer cheap cipro pills treatment. Besides the cheap cipro pills possibility of altering the microbiome, he said doctors might be able to use patients' microbiome makeup as a "biomarker" of their risk of progression.More informationThe American Cancer Society has more on cancer immunotherapy.SOURCES. Leopoldo Segal, M.D., M.S., director, Lung Microbiome Program, and associate professor, medicine, New York University Grossman School of Medicine, New York City. John Heymach, M.D., Ph.D., chair, thoracic/head and neck medical oncology, University cheap cipro pills of Texas M.D.

Anderson Cancer Center, Houston cheap cipro pills. Thomas Marron, M.D., Ph.D., assistant director, Early Phase and Immunotherapy Trials, Tisch Cancer Institute at Mount Sinai, New York City. Cancer Discovery, cheap cipro pills online, Nov. 11, 2020Copyright © cheap cipro pills 2020 HealthDay.

All rights reserved. From Cancer Resources cheap cipro pills Featured Centers Health Solutions From Our SponsorsLatest Men's Health News By Steven Reinberg HealthDay ReporterTHURSDAY, Nov. 12, 2020 (HealthDay News)Young men who consider using the drug Propecia to prevent baldness may be putting themselves at risk for depression and suicide, a new study cheap cipro pills suggests.Information from the World Health Organization indicates that over the past 10 years, reports of suicidal ideation among young men using the drug have increased, rising significantly after 2012, the researchers said."There are many possible explanations for our findings," said senior researcher Dr. Quoc-Dien Trinh, from the division of urologic surgery at Brigham and Women's Hospital, in Boston.Either there is some sort of biological explanation linking Propecia (finasteride) to suicidality and psychological adverse events, or media attention, which heightened awareness and may have increased reporting of adverse events, may have played a role, he said."Patients should be made aware of this potential side effect and speak to their prescribing doctor if they have concerns," Trinh said.Finasteride was developed to shrink enlarged prostates, a condition called benign prostatic hyperplasia.

Its use was later extended to treat male-pattern baldness.Trinh's team used data from VigiBase, which gathers information from 153 countries on cheap cipro pills all adverse drug reactions and contains more than 20 million safety reports.The researchers found 356 reports of suicidality and nearly 3,000 reports of other psychological problems among people taking finasteride.Most of these reports for suicidal ideation, depression and anxiety were among men taking finasteride for hair loss who were 45 and younger.These findings were not seen in older patients taking the drug for enlarged prostate glands.According to Dr. Michael Irwig, from the division of endocrinology at Beth Israel Deaconess Medical Center, in Boston, "The difference between finasteride in younger men versus older men is likely related to the severe toll this medication can take on younger men who develop persistent sexual side effects."A dramatic loss in sexual function in a younger man can lead to significant dating and relationship difficulties, which is less likely to be an issue in older men who may already have sexual dysfunction due to aging and who are already in a stable relationship, he noted."Sexual dysfunction in younger men can result in depression and, in a subset of these men, suicidal ideation," Irwig said.Trinh said that these findings should not be over-interpreted to say that finasteride causes suicides, only that there seems to be an association.He thinks, however, that many more young men taking finasteride contemplate suicide than reported to VigiBase.Abdulmaged Traish, a professor emeritus of urology at Boston University School of Medicine, believes that finasteride has a biological effect cheap cipro pills that disrupts the central nervous system in some young patients, which can have psychological effects like depression and suicide.The drug can help some people, he said. "But it comes with a high price, especially for a nonthreatening disorder like alopecia [hair loss]," he noted. "It's not a disease that kills people."If a man wants to try finasteride for hair loss, he should at least be told of the risks, Traish said."Physicians should cheap cipro pills have a frank, open discussion with the patient about the potential adverse side effects of the drug," he said.

"If the patient still wants to take it, it's OK, but at least tell him, cheap cipro pills honestly, this is what we know."Traish also thinks that the U.S. Food and Drug Administration should have a "boxed warning" that the drug may cause suicide ideation in some young men. No such warning is on cheap cipro pills the package insert now.The report was published online Nov. 11 in JAMA Dermatology.More information cheap cipro pills QUESTION It is normal to lose 100-150 hairs per day.

See Answer For more on depression in men, head to the National Institute of Mental Health.SOURCES. Quoc-Dien Trinh, MD, division of urologic surgery, Brigham and Women's Hospital, Boston cheap cipro pills. Abdulmaged Traish, Ph.D., professor emeritus, urology, Boston University School of Medicine. Michael Irwig, cheap cipro pills MD, division of endocrinology, Beth Israel Deaconess Medical Center, Boston.

JAMA Dermatology, cheap cipro pills Nov. 11, 2020, onlineCopyright © 2020 HealthDay. All rights cheap cipro pills reserved. From Healthy Resources Featured Centers Health Solutions From Our SponsorsLatest Depression cheap cipro pills News FRIDAY, Nov.

13, 2020The antidepressant drug fluvoxamine -- best known by the brand name Luvox -- may help prevent serious illness in buy antibiotics patients who aren't yet hospitalized, a new study finds.The study included 152 patients infected with mild-to-moderate buy antibiotics. Of those, 80 took fluvoxamine and 72 took a placebo for 15 days.By the end of that time, none of the patients who took the drug had seen their progress to serious illness, compared with six (8.3%) of the cheap cipro pills patients who took the placebo, according to researchers at Washington University School of Medicine in St. Louis."The patients who took fluvoxamine did not develop serious breathing difficulties or require hospitalization for cheap cipro pills problems with lung function," said first author Dr. Eric Lenze, professor of psychiatry."Most investigational treatments for buy antibiotics have been aimed at the very sickest patients, but it's also important to find therapies that prevent patients from getting sick enough to require supplemental oxygen or to have to go to the hospital.

Our study suggests fluvoxamine may help fill that niche," Lenze noted in a university news release.Fluvoxamine -- widely used to treat depression, obsessive-compulsive disorder cheap cipro pills and social anxiety disorder -- is a type of drug called a selective serotonin-reuptake inhibitor (SSRI). This class of drugs also includes medicines such as Prozac, Zoloft and Celexa.But unlike other SSRIs, fluvoxamine has a strong interaction with a protein called the sigma-1 receptor, which helps regulate the body's inflammatory response."There are several ways this drug might work to help buy antibiotics patients, but we think it most likely may cheap cipro pills be interacting with the sigma-1 receptor to reduce the production of inflammatory molecules," explained study senior author Dr. Angela Reiersen, associate professor of psychiatry."Past research has demonstrated that fluvoxamine can reduce inflammation in animal models of sepsis, and it may be doing something similar in our patients," she said in the release.By reducing inflammation, fluvoxamine may prevent a hyperactive immune response in buy antibiotics patients. That, in turn, may decrease their risk of serious illness and death, Reiersen said."Our goal is to help patients who cheap cipro pills are initially well enough to be at home and to prevent them from getting sick enough to be hospitalized," Dr.

Caline Mattar, assistant cheap cipro pills professor of medicine in the Division of Infectious Diseases, said in the release. "What we've seen so far suggests that fluvoxamine may be an important tool in achieving that goal."Dr. Amesh Adalja is a senior scholar at the Johns Hopkins Center for Health cheap cipro pills Security in Baltimore. He wasn't cheap cipro pills involved in the study, but said the research is "notable not only because of its positive outcome -- we desperately need a medication that keeps buy antibiotics patients out of the hospital -- but also because of the manner in which it was conducted."But Adalja stressed that a larger trial is needed "to see if the promising findings hold up."The researchers said they plan to begin such a study in the next few weeks and it will include patients from across the United States.The preliminary study was published online Nov.

12 in the Journal of the American Medical Association.More informationFor more on buy antibiotics, go to the U.S. Centers for Disease Control and Prevention.SOURCES cheap cipro pills. Amesh Adalja, cheap cipro pills M.D., senior scholar, Johns Hopkins Center for Health Security, Baltimore. Washington University in St.

Louis, news release, Nov cheap cipro pills. 12, 2020Ernie MundellCopyright © cheap cipro pills 2020 HealthDay. All rights reserved. SLIDESHOW Learn to Spot Depression cheap cipro pills.

Symptoms, Warning Signs, Medication See SlideshowLatest cheap cipro pills antibiotics News By Dennis Thompson HealthDay ReporterTHURSDAY, Nov. 12, 2020 (HealthDay News)Early buy antibiotics treatment trial results announced by Pfizer this week caused hopes to soar for a swift end to the cipro that has killed more than 242,000 and infected more than 10 million in the United States alone.But even if the preliminary results released Monday pan out, it will still take many months to produce enough of the treatment to inoculate everyone in the United States, experts warn.The health care industry will also face special distribution challenges related to this particular treatment, which must be maintained in extremely cold storage and delivered in a two-shot regimen."People should be enthusiastic, but realize that the benefits that we get from that treatment are not going to be in the winter, they're not going to be now, in the short range. They're going cheap cipro pills to be going forward, likely in the spring to summer of 2021," said Dr. Amesh Adalja, a senior scholar cheap cipro pills with the Johns Hopkins Center for Health Security, in Baltimore."It shouldn't change your approach to the cipro today, tomorrow, next week, next month," he added.

"We are entering a period of the year where we're seeing intensification of spread all over the country. We need to be very vigilant cheap cipro pills. The cases are getting to cheap cipro pills the point where they are inundating hospitals in some states. The trajectory of the cipro right now looks very bad for the winter."Adalja's words echo those of President-elect Joe Biden, who lauded news of Pfizer's treatment success but asked Americans to stay vigilant."America is still losing over 1,000 people a day from buy antibiotics, and that number is rising -- and will continue to get worse unless we make progress on masking and other immediate actions," Biden said on Monday.

"That is the reality for now, and cheap cipro pills for the next few months. Today's announcement promises cheap cipro pills the chance to change that next year, but the tasks before us now remain the same."'No serious safety concerns'The early information from Pfizer -- more than 90% effective -- is extremely encouraging, said Dr. Thad Stappenbeck, head of the Lerner Research Institute at the Cleveland Clinic, in Ohio."It means if you get the treatment, based on their early statistics you have a 90% chance if you encounter the cipro of not being infected, which is remarkable," Stappenbeck said. Pfizer had set a goal of 50% effectiveness for its treatment -- the average cheap cipro pills effectiveness of the annual flu shot.Of more than 43,500 people who got either the treatment or a placebo, there have been 94 confirmed cases of buy antibiotics, Pfizer said in its early analysis."Nearly all of the new s were in the placebo group," Stappenbeck said.Pfizer needs to spend a few more weeks collecting safety data before it can apply for an emergency use authorization from the U.S.

Food and Drug Administration, but Stappenbeck expressed confidence that the treatment cheap cipro pills would prove safe."They've now gone from just a few dozen people or a few hundred people now to tens of thousands of people, and no serious safety concerns," he said.Pfizer aims to produce up to 50 million doses of the treatment by year's end -- enough to inoculate 25 million people -- and up to 1.3 billion doses in 2021.Pfizer is making the treatment at facilities in Kalamazoo, Mich., and Puurs, Belgium, according to The New York Times. Doses distributed in the United States will mostly come from Kalamazoo.The U.S. Government has placed an initial order for 100 million doses of the treatment, at a cost of $1.95 billion, with an option to buy another 500 million doses, Politico reports."There's a goal of 660 million doses, so there's two doses for everyone in the United States that cheap cipro pills wants one," said Anna Legreid Dopp, senior director of clinical guidelines and quality improvement with the American Society of Health-System Pharmacists (ASHP), in Bethesda, Md.Who's first in line?. The early doses likely will be given to health care workers and first responders, Dopp said, followed by people at high risk for severe buy antibiotics s.But distributing the doses across the country cheap cipro pills is expected to be a challenge in and of itself.The treatment has to be stored at around minus 94 degrees Fahrenheit, which is about as cold as it gets at the South Pole on a winter's day.

The shot can withstand normal refrigeration only for about 24 hours, and room temperature for no more than two hours after thawing, Politico reports.Creating a "cold chain" of distribution that will keep the treatment frozen until it's time for a person's shot "absolutely is going to be an added burden," Adalja said."This doesn't just need to be kept at ordinary refrigerator temperatures. It needs to be kept at minus 70, minus 80 Centigrade, which is not something that most places have the ability cheap cipro pills to do no matter where you are in the United States, let alone the developing world," Adalja said.These sorts of freezers are common at academic centers, and might even be found at community hospitals, Stappenbeck said. "These are not cheap cipro pills super expensive. They're $5,000 or $6,000," he added.Major shipping companies United Parcel Service (UPS) and FedEx are scrambling to build freezer farms in major hub cities across the nation, according to The New York Times.

Airplanes and trucks also will need to be fitted with freezers.Dopp said other innovations are in the works, such as "thermal suitcases cheap cipro pills that allow some flexibility if you don't have access to a freezer."Two-dose regimenThe other distribution problem that must be solved is timing. People need to get the treatment in two doses, separated by about a month, Dopp said.Hospitals, doctors and pharmacies will need to cheap cipro pills set up computer systems to track patients and make sure they get their second dose in a timely fashion, Dopp said. Otherwise, they won't get full protection from the treatment, and perhaps none at all.One other concern, 10 other buy antibiotics treatment candidates are in the final stages of testing, Dopp noted. As they get approved, doctors will need to track which patients have received which treatment."A patient can't get one treatment for their first dose and a different treatment from a different manufacturer for their second dose," she said.ASHP was concerned that as hospitals begin handing out the first shots, they would cheap cipro pills need to keep at least half their initial allotments in reserve so people could get their second shot on time."The answer we received from the U.S.

Centers for Disease Control and Prevention is that they do not, that they will cheap cipro pills work to provide just-in-time second doses, which I think is encouraging because it does allow for more people to start on their series," Dopp said.More informationLearn more about Pfizer's treatment.SOURCES. Amesh Adalja, MD, senior scholar, Johns Hopkins Center for Health Security, Baltimore. Thad Stappenbeck, MD, cheap cipro pills PhD, chair, Lerner Research Institute, Cleveland Clinic, Ohio. Anna Legreid Dopp, PharmD, senior director, cheap cipro pills clinical guidelines and quality improvement, American Society of Health-System Pharmacists, Bethesda, Md..

The New York Times. PoliticoCopyright © 2020 HealthDay. All rights reserved..

Buy cipro online without prescription

Diagnostic errors in hospital medicine have Kamagra for sale melbourne mostly remained in uncharted waters.1 This is partly because several factors make measurement buy cipro online without prescription of diagnostic errors challenging. Patients are often admitted to hospitals with a tentative diagnosis and need additional diagnostic investigations to buy cipro online without prescription determine next steps. This evolving nature of a diagnosis makes it hard to determine when the correct diagnosis could have been established and if a more specific diagnosis was needed to start the right treatment.2 Hospitalised patients also may have diagnoses that are atypical or rare and pose dilemmas for treating clinicians.

As a result, delays buy cipro online without prescription in diagnosis may not necessarily be related to a diagnostic error. Furthermore, what types of diagnostic errors occur in the hospital and their prevalence depends on how one buy cipro online without prescription defines them. Different approaches to define them have included counting missed, wrong or delayed diagnoses regardless of whether there was a process error;3 counting them only when there was a clear ‘missed opportunity’ – ie, something different could have been done to make the correct or timely diagnosis;4 or diagnostic adverse events (ie, diagnostic errors resulting in harm);5 all leading to views of the problem through different lenses.Two articles in this issue of the journal provide new insights into the epidemiology of diagnostic errors in hospitalised patients.6 7 Gunderson and colleagues conducted a systematic review to determine the prevalence of harmful diagnostic errors in hospitalised patients.6 Raffel and colleagues studied readmitted patients using established methods for diagnostic error detection and analysis to gain insights into contributing factors.7 Both studies advance the science of measurement and understanding of how to reduce diagnostic error in hospitals.

We discuss buy cipro online without prescription the significance of the results for hospital medicine and implications for emerging research and practice improvement efforts.Finding diagnostic errors in hospitalsGunderson and colleagues performed a systematic review and meta-analysis to inform a new estimate for the prevalence of diagnostic adverse events among hospitalised patients, a rate of 0.7%.6 Their review shows how diagnostic error is a global problem, with studies from countries across five continents. The prevalence however is lower than what might be expected looking at previous research, mostly in outpatient care, and based on expert estimates.8–11 The prevalence of diagnostic error in hospital care may be lower because outpatient care, especially primary care, has the challenging task of identifying patients with a serious disease from a large sample of patients who present with common symptoms and mostly benign non-urgent diseases. A higher state buy cipro online without prescription of attention in the hospital and higher prior probability of a patient having a more serious disease may also reduce the likelihood of something being missed (ie, the prevalence effect).12 13 Furthermore, the hospital setting offers more diagnostic evaluation possibilities (consultations, imaging, laboratory) and more members of the diagnostic team to alert a clinician on the wrong diagnostic track.The heterogeneity of the studies in the review and meta-analysis and a broad scope may also explain the lower prevalence rate.6 14 The included studies did not have an exclusive focus on detecting diagnostic errors but rather aimed to identify all types of adverse events, including medication and surgical adverse events,5 15 which are relatively easier to measure.

Consequently, the data collection buy cipro online without prescription instruments were likely not sufficiently sensitive to pick up diagnostic adverse events, resulting in an underestimation. Some diagnostic adverse events may also be classified as ‘other’ types. For instance delayed diagnosis of a wound leakage after surgery buy cipro online without prescription is often considered a surgical complication and not categorised as a delay in diagnosis.16 Studies in the review also detected adverse events (ie, errors that resulted in harm)6 which is a subgroup of diagnostic errors, because not every diagnostic error results in harm.17 Lastly, while the random selection of patients is a strength for determining prevalence of medical error, not all admissions involve making a diagnosis—patients are often hospitalised for treatment and procedures.

As the literature in the area becomes more robust, future reviews may be able to provide an updated estimate. For now, Gunderson and colleagues estimate 250,000 diagnostic adverse buy cipro online without prescription events occur annually in the USA, which should be alarming enough to warrant attention and intervention.While the study by Raffel and colleagues is not a true prevalence study (it only evaluated 7-day readmissions), it uses dedicated tools to identify diagnostic error in hospitals, a crucial next step. By examining a subset of hospital buy cipro online without prescription admissions at greater risk of diagnosis-related problems (ie, readmissions within 7 days after hospital discharge) and by using tools dedicated to identifying diagnostic error, the investigators were able to describe error types and contributing factors.

The advantage of studying such a high-risk sample is that diagnostic errors can be found more efficiently, that is, the positive predictive value is higher than if you review all consecutive patients. This could identify a higher number buy cipro online without prescription of cases to identify contributing factors. While the positive predictive value they achieved through this method was still rather low, methods to selectively identify diagnostic errors are valuable in measurement efforts.

Future studies could build on this work to develop sampling methods with higher predictive values that can be used by others for research and practice improvement.Diseases at risk for diagnostic error in the hospital settingTypes of conditions involved in diagnostic error in both studies buy cipro online without prescription reflect a broad range of diseases commonly identified in previous studies, such as malignancies, pulmonary embolism, aortic aneurysm and s.5 8 18 A recent malpractice claims-based study has led some to suggest that initial diagnostic error reduction efforts, including allocation of funding for research and quality measurement/improvement, should focus on three broad types of disease categories, the so-called ‘Big Three’, namely cancer, s and cardiovascular diseases, because they are highly prevalent and result in significant harm.11 19 20 These three disease categories cover a large portion of diagnoses made in medicine. Indeed, data beyond claims also suggest that diagnostic errors in each of these categories are common.5 18 However, diagnostic errors span a large range of other diseases as shown in both studies, which is similar to what prior studies buy cipro online without prescription have found. For instance, in one primary care study, 68 unique diagnoses were missed with the most common condition accounting for only 6.7% of errors.21Contributing factors in hospital medicineRaffel and colleagues applied established tools (ie, SAFER Dx22 and DEER23) to identify contributing factors.

They found that most of these involved failures in clinical buy cipro online without prescription assessment and/or testing. Contributing factors in these two domains occurred in more than 90% of diagnostic errors, a high proportion consistent with previous work.8 17 buy cipro online without prescription 18 Furthermore, these main contributing factors are common across diagnostic errors regardless of the diseases involved. For instance, similar process breakdowns emerge across different types of missed cancer diagnoses.24–26Finding ‘Forests’ not just the ‘Big Trees’ to enable scientific progressSo should initial scientific efforts just target disease categories?.

And if so, should buy cipro online without prescription they address just the ‘Big Three’?. Data from prior studies across different settings, including those from Gunderson and Raffel and colleagues, find large diversity in misdiagnosed diseases.5–7 18 21 27 This suggests that an exclusive focus on the ‘Big Three’ would neglect a substantial proportion of other common and harmful diagnostic errors.27 Furthermore, research on contributing factors of diagnostic errors reveals a number of common system and process factors that would require robust disease-agnostic approaches. If funding and advocacy for diagnostic safety becomes mostly disease oriented, it will pull resources away from broader ‘disease-agnostic’ research and quality improvement efforts needed to understand and address these underlying system and process factors.28 Biomedical research is already quite disease focused and supported by many disease-specific institutes and this now needs to be balanced by buy cipro online without prescription work that catalyses much-needed foundational and cross-cutting healthcare delivery system improvements.We would thus recommend a balanced strategy that carefully combines disease-specific and disease-agnostic approaches to help address common contributing factors, system issues and process breakdowns for diagnostic error that cut across these many unique diseases.

For example, if new quality measures to quantify delays in colorectal cancer diagnosis and missed diagnosis of sepsis are developed, we would also need ‘disease-agnostic’ studies that evaluate buy cipro online without prescription the implementation and effectiveness of such measures. This includes how they fit within current measurement programmes, what their measurement burden is and what the unintended consequences may be. A combined approach would create more synergistic and collaborative understanding in addition to enabling application of buy cipro online without prescription common frameworks and approaches to multiple conditions, rather than ‘reinventing the wheel’ for each disease or disease category.

This type of approach may have a larger population-based impact and help us see the entire ‘forest’ to reduce diagnostic error.Implications for practice improvementA crucial first step for improving diagnosis in hospitals is to create programmes to identify and analyse diagnostic errors.29 Most hospitals have systems and programmes in place to report and analyse safety issues such as falls, surgical complications and medication errors, but they do not capture diagnostic errors. With increased recognition of risks for diagnostic error, hospitals should use recent guidance, such buy cipro online without prescription as from the US Agency for Healthcare Research and Quality, and consider pragmatic measurement approaches to start identifying and learning from diagnostic errors.30To reduce cognitive errors, ‘cognitive debiasing strategies’ have been widely recommended.31 However, there is increasing evidence that those strategies are not effective for diagnostic error reduction and recent insights have revealed lack of knowledge as the fundamental cause of errors in the diagnostic reasoning process.32–34 Next steps for practice improvement would therefore need to involve studying the role of knowledge and its interplay with cognitive processes. Interventions should explore opportunities to increase clinicians’ knowledge base (eg, by education and feedback) as well as testing and implementing clinical buy cipro online without prescription decision support systems to allow for timely access to the relevant knowledge.

While specific interventions need more development and testing, other general safety practices such as better collaboration with the laboratory and radiology departments to facilitate more accurate ordering and interpretation of the tests,33 are ready for adoption.ConclusionsTwo studies6 7 of diagnostic error in hospital medicine—by Gunderson and colleagues and Raffel and colleagues—have advanced our knowledge about its epidemiology. Consistent with prior studies, a large range of diseases buy cipro online without prescription and a whole host of common contributory factors are involved. Although the estimated prevalence of diagnostic error relies on data from prior studies conducted during an era of limited dedicated tools to identify diagnostic errors, these numbers have significant research and practice implications.

Measurement science buy cipro online without prescription is still evolving but both studies should inspire all hospitals to apply more contemporary methods to identify and analyse diagnostic errors for learning and improvement. Given that errors across multiple diseases in multitude of settings have many common contributing factors, disease-agnostic approaches focused on common systems and process contributory factors are likely to have significant benefit buy cipro online without prescription and should be emphasised in further research and development efforts.Patient advocates have long called for patients to have access to all of their healthcare data, including electronic health records (EHRs).1 In parallel, experts have suggested that providing patients with access to EHRs will improve patient engagement, care quality, and, by extension, health/healthcare outcomes.2 Prior observational studies have supported some of these claims—for example, documenting that patients are overwhelmingly interested in and satisfied with receiving their healthcare data electronically,3 to finding that patients do identify errors when they read physician notes in the EHR.4 Because studies of EHR access for patients have been conducted and disseminated across disparate clinical conditions and settings and often using varied methodologies, the systematic review by Neves et al in this issue of BMJ Quality &. Safety provides a valuable contribution in assessing the impact of patients’ EHR access specifically within the randomised controlled trial (RCT) literature.5 Their meta-analysis demonstrates some significant but potentially limited benefits within these 20 RCTs that involved sharing EHR data/access with patients.Overall, Neves et al found a few clear trends.

First, there was a consistent, modest improvement in glycaemic control in RCTs targeting patients with diabetes, reinforcing the observational research focused on portal buy cipro online without prescription use for diabetes care.6 In addition, patient access to EHRs seemed to support safety of care in facilitating medication adherence and identification of medication discrepancies. These results are similar to observational studies,7 as well as a recent scoping review of patient engagement interventions to promote buy cipro online without prescription the safety of care and to improve short-term and intermediate-term clinical outcomes.8 Finally, for patient-reported outcomes ranging from self-efficacy to patient activation to patient satisfaction, results were mixed, with about half of included studies showing some improvement. Thus, this review highlighted a wide variation and potential lack of consensus about what patient-centred outcome to include in studying EHR-enabled interventions, given the diffuse set of behaviours that could be targeted.

More importantly, this review highlights that none of the included studies, many of which are older, focused on equity as a primary objective of the work (and buy cipro online without prescription very few even included data on racial/ethnic, educational attainment, digital literacy and/or health literacy differences9 10)—even though there are known barriers to digital health interventions by these characteristics.Despite the modest benefits seen in these 20 randomised trials of EHR-facilitated complex care interventions, we still believe in the clinical value and potential improvement in patient-reported outcomes in this space. A more careful examination of the 20 included studies in this review actually sheds important light on delivering complex interventions to improve quality of care, during which patient access to EHRs was implemented in varied ways that might have led to more muddled results. For example, many of the included studies tested evidence-based practices that are known to independently enhance the quality of care, such as patient outreach buy cipro online without prescription and reminders for healthcare tasks, self-management training and increased healthcare provider communication access.

Therefore, without detailed behavioural pathways for the targeted intervention components buy cipro online without prescription surrounding EHR data access, it is challenging to interpret observed trial effects. In our opinion and in our previous work,11 one-time action by systems or clinics granting patient access to EHRs is unlikely to replicate the effect of these interventions. In particular, buy cipro online without prescription access versus training to use EHRs should likely be considered separately, as well as the study of specific features within the EHR.

For example, passive provision of medical information from the EHR via online portals (eg, after-visit summaries or list of immunisations) differs substantially from active communication or completion of healthcare tasks via EHR-linked websites (eg, secure messaging exchanges between patients and providers about medical concerns or medication refill requests).Therefore, we hope that this review can push the field beyond RCTs of patient access to EHR data and into specific mechanisms for patient uptake/use that could be more generalisable. First and foremost, it is now generally buy cipro online without prescription accepted that patients have the right to view their own health data, both because of their ownership of that information and the convenience it may offer. This indicates that it will likely be impossible to randomise patients to either receive or not receive EHR data in the future, buy cipro online without prescription and interventions surrounding universal EHR data access could be more specific to targeted behaviours.

For example, now that patient electronic access to data is here to stay, future attention to research methods that tailor interventions, tease apart core implementation strategies, and engage patients and providers in codesign will be important next steps to ensure efficiency and relevance. Finally, and perhaps most importantly, RCT participants often differ significantly from target populations, with volunteers often exhibiting higher educational attainment and less buy cipro online without prescription racial/ethnic diversity.12 Given known disparities in patient EHR access by race/ethnicity, socioeconomic status and health literacy mentioned previously, these trials are not likely to generalise to more diverse populations.Moving forward, the results of this review highlight several principles for future studies of technology-facilitated healthcare delivery. First, all studies need to both include diverse participants and report on race, ethnicity, educational attainment, and health and digital literacy.13 Second, future work must focus on both internal and external validity of patient access/use of EHR data.

The review by Neves et al gives us some clearer understanding of the internal validity of studies on clinical and patient-reported outcomes, but it remains unclear what impact these types of interventions will have on health outcomes across an entire healthcare system or region outside buy cipro online without prescription of RCT samples. Studies of patient EHR access/use can move into the external validity space (even while conducting RCTs)14 by including implementation outcomes, such as the proportion of individuals offered EHR access who take it up, the extent of use over time, the type/features used, and costs for providers and staff, in addition to effectiveness in promoting health outcomes and differences across socioeconomic status, racial/ethnic groups and literacy levels.Like patient advocates and experts for many years, we absolutely agree that patient records belong to patients and should be readily available in structured, electronic form for patients and families.15 Given the complexity of the information provided buy cipro online without prescription and the specific context for interacting or supporting patients in completing tasks via online patient portals/platforms, we should not expect access alone to ameliorate current gaps in care or significantly improve morbidity and mortality. As more care becomes digital-first (ie, with virtual care and telemedicine), there are real concerns about widening healthcare disparities for low-income, racial–ethnic minority and linguistically diverse populations.

Our specific recommendations to avoid such undesirable developments moving forward includeWider measurement of patient interest and access/skills to using technology-based health platforms and tools.Tailoring of interventions to match patient preferences and needs, such as by digital literacy skills as well as inclusion of caregivers/families to support use.Use of mixed method and implementation science studies to understand use, usability, and uptake alongside clinical impact and effectiveness.Attention to these points will allow us to buy cipro online without prescription understand the ways in which patient portals and other forms of EHR access for patients may produce different impacts across distinct patient groups. This understanding will not only mitigate potential adverse effects for vulnerable groups but also achieve the intended goal of improving healthcare quality for all patients through freer access to information about their care..

Diagnostic errors in hospital medicine have mostly remained cheap cipro pills in uncharted waters.1 read this article This is partly because several factors make measurement of diagnostic errors challenging. Patients are often admitted to hospitals with a tentative diagnosis and need additional cheap cipro pills diagnostic investigations to determine next steps. This evolving nature of a diagnosis makes it hard to determine when the correct diagnosis could have been established and if a more specific diagnosis was needed to start the right treatment.2 Hospitalised patients also may have diagnoses that are atypical or rare and pose dilemmas for treating clinicians.

As a result, delays in diagnosis may not necessarily be related to a diagnostic error cheap cipro pills. Furthermore, what types cheap cipro pills of diagnostic errors occur in the hospital and their prevalence depends on how one defines them. Different approaches to define them have included counting missed, wrong or delayed diagnoses regardless of whether there was a process error;3 counting them only when there was a clear ‘missed opportunity’ – ie, something different could have been done to make the correct or timely diagnosis;4 or diagnostic adverse events (ie, diagnostic errors resulting in harm);5 all leading to views of the problem through different lenses.Two articles in this issue of the journal provide new insights into the epidemiology of diagnostic errors in hospitalised patients.6 7 Gunderson and colleagues conducted a systematic review to determine the prevalence of harmful diagnostic errors in hospitalised patients.6 Raffel and colleagues studied readmitted patients using established methods for diagnostic error detection and analysis to gain insights into contributing factors.7 Both studies advance the science of measurement and understanding of how to reduce diagnostic error in hospitals.

We discuss the significance of the results for hospital medicine and implications for emerging research and practice improvement efforts.Finding diagnostic errors in hospitalsGunderson and colleagues performed a systematic cheap cipro pills review and meta-analysis to inform a new estimate for the prevalence of diagnostic adverse events among hospitalised patients, a rate of 0.7%.6 Their review shows how diagnostic error is a global problem, with studies from countries across five continents. The prevalence however is lower than what might be expected looking at previous research, mostly in outpatient care, and based on expert estimates.8–11 The prevalence of diagnostic error in hospital care may be lower because outpatient care, especially primary care, has the challenging task of identifying patients with a serious disease from a large sample of patients who present with common symptoms and mostly benign non-urgent diseases. A higher state of attention in the hospital and higher prior probability of a patient having a more serious disease may also reduce the likelihood of something being missed (ie, the prevalence effect).12 13 Furthermore, cheap cipro pills the hospital setting offers more diagnostic evaluation possibilities (consultations, imaging, laboratory) and more members of the diagnostic team to alert a clinician on the wrong diagnostic track.The heterogeneity of the studies in the review and meta-analysis and a broad scope may also explain the lower prevalence rate.6 14 The included studies did not have an exclusive focus on detecting diagnostic errors but rather aimed to identify all types of adverse events, including medication and surgical adverse events,5 15 which are relatively easier to measure.

Consequently, the data collection instruments were likely not sufficiently sensitive cheap cipro pills to pick up diagnostic adverse events, resulting in an underestimation. Some diagnostic adverse events may also be classified as ‘other’ types. For instance delayed diagnosis of a wound leakage after surgery is often considered a surgical complication and not categorised as a delay in diagnosis.16 Studies in the review also detected adverse events (ie, errors that resulted in harm)6 which is a subgroup of diagnostic errors, because not every diagnostic error results in harm.17 Lastly, while the random selection of patients is a strength for determining prevalence of medical error, not all admissions involve making a cheap cipro pills diagnosis—patients are often hospitalised for treatment and procedures.

As the literature in the area becomes more robust, future reviews may be able to provide an updated estimate. For now, Gunderson and colleagues estimate 250,000 diagnostic adverse events occur annually in the USA, which should be alarming enough to warrant attention and intervention.While the study by Raffel and colleagues is not a true prevalence study (it only evaluated 7-day readmissions), it uses dedicated tools to identify diagnostic error in hospitals, cheap cipro pills a crucial next step. By examining a subset cheap cipro pills of hospital admissions at greater risk of diagnosis-related problems (ie, readmissions within 7 days after hospital discharge) and by using tools dedicated to identifying diagnostic error, the investigators were able to describe error types and contributing factors.

The advantage of studying such a high-risk sample is that diagnostic errors can be found more efficiently, that is, the positive predictive value is higher than if you review all consecutive patients. This could identify a higher number of cases to cheap cipro pills identify contributing factors. While the positive predictive value they achieved through this method was still rather low, methods to selectively identify diagnostic errors are valuable in measurement efforts.

Future studies could build on this work to develop sampling methods with higher predictive values that can be used by others for research and practice improvement.Diseases at risk cheap cipro pills for diagnostic error in the hospital settingTypes of conditions involved in diagnostic error in both studies reflect a broad range of diseases commonly identified in previous studies, such as malignancies, pulmonary embolism, aortic aneurysm and s.5 8 18 A recent malpractice claims-based study has led some to suggest that initial diagnostic error reduction efforts, including allocation of funding for research and quality measurement/improvement, should focus on three broad types of disease categories, the so-called ‘Big Three’, namely cancer, s and cardiovascular diseases, because they are highly prevalent and result in significant harm.11 19 20 These three disease categories cover a large portion of diagnoses made in medicine. Indeed, data beyond claims also suggest that diagnostic errors in each of these categories are common.5 18 However, diagnostic errors span a large cheap cipro pills range of other diseases as shown in both studies, which is similar to what prior studies have found. For instance, in one primary care study, 68 unique diagnoses were missed with the most common condition accounting for only 6.7% of errors.21Contributing factors in hospital medicineRaffel and colleagues applied established tools (ie, SAFER Dx22 and DEER23) to identify contributing factors.

They found that most of these cheap cipro pills involved failures in clinical assessment and/or testing. Contributing factors in these two domains occurred in more than 90% of diagnostic errors, a high proportion consistent with previous work.8 17 18 Furthermore, cheap cipro pills these main contributing factors are common across diagnostic errors regardless of the diseases involved. For instance, similar process breakdowns emerge across different types of missed cancer diagnoses.24–26Finding ‘Forests’ not just the ‘Big Trees’ to enable scientific progressSo should initial scientific efforts just target disease categories?.

And cheap cipro pills if so, should they address just the ‘Big Three’?. Data from prior studies across different settings, including those from Gunderson and Raffel and colleagues, find large diversity in misdiagnosed diseases.5–7 18 21 27 This suggests that an exclusive focus on the ‘Big Three’ would neglect a substantial proportion of other common and harmful diagnostic errors.27 Furthermore, research on contributing factors of diagnostic errors reveals a number of common system and process factors that would require robust disease-agnostic approaches. If funding and advocacy for diagnostic safety becomes mostly disease oriented, it will pull resources away from broader ‘disease-agnostic’ research and quality improvement efforts needed to understand and address these underlying system and process factors.28 cheap cipro pills Biomedical research is already quite disease focused and supported by many disease-specific institutes and this now needs to be balanced by work that catalyses much-needed foundational and cross-cutting healthcare delivery system improvements.We would thus recommend a balanced strategy that carefully combines disease-specific and disease-agnostic approaches to help address common contributing factors, system issues and process breakdowns for diagnostic error that cut across these many unique diseases.

For example, if new quality measures to quantify delays in colorectal cancer diagnosis cheap cipro pills and missed diagnosis of sepsis are developed, we would also need ‘disease-agnostic’ studies that evaluate the implementation and effectiveness of such measures. This includes how they fit within current measurement programmes, what their measurement burden is and what the unintended consequences may be. A combined approach would create more synergistic and collaborative understanding in addition to enabling application of common frameworks and approaches to multiple conditions, rather than ‘reinventing the wheel’ cheap cipro pills for each disease or disease category.

This type of approach may have a larger population-based impact and help us see the entire ‘forest’ to reduce diagnostic error.Implications for practice improvementA crucial first step for improving diagnosis in hospitals is to create programmes to identify and analyse diagnostic errors.29 Most hospitals have systems and programmes in place to report and analyse safety issues such as falls, surgical complications and medication errors, but they do not capture diagnostic errors. With increased recognition of risks for diagnostic error, hospitals should use recent guidance, such as from the US Agency for Healthcare Research and Quality, and consider pragmatic measurement approaches to start identifying and learning from diagnostic errors.30To reduce cognitive errors, ‘cognitive debiasing strategies’ have been widely recommended.31 However, there is increasing evidence that those strategies are cheap cipro pills not effective for diagnostic error reduction and recent insights have revealed lack of knowledge as the fundamental cause of errors in the diagnostic reasoning process.32–34 Next steps for practice improvement would therefore need to involve studying the role of knowledge and its interplay with cognitive processes. Interventions should explore opportunities to increase clinicians’ knowledge base (eg, by education and feedback) cheap cipro pills as well as testing and implementing clinical decision support systems to allow for timely access to the relevant knowledge.

While specific interventions need more development and testing, other general safety practices such as better collaboration with the laboratory and radiology departments to facilitate more accurate ordering and interpretation of the tests,33 are ready for adoption.ConclusionsTwo studies6 7 of diagnostic error in hospital medicine—by Gunderson and colleagues and Raffel and colleagues—have advanced our knowledge about its epidemiology. Consistent with prior cheap cipro pills studies, a large range of diseases and a whole host of common contributory factors are involved. Although the estimated prevalence of diagnostic error relies on data from prior studies conducted during an era of limited dedicated tools to identify diagnostic errors, these numbers have significant research and practice implications.

Measurement science is still evolving but both cheap cipro pills studies should inspire all hospitals to apply more contemporary methods to identify and analyse diagnostic errors for learning and improvement. Given that errors across multiple diseases in multitude of settings have many common contributing factors, disease-agnostic approaches focused on common systems and process contributory factors are likely to have significant benefit and should be emphasised in further research and development efforts.Patient advocates have long called for patients to have access to all of their healthcare data, including electronic health records (EHRs).1 In parallel, experts have suggested that providing patients with access to EHRs will improve patient engagement, care quality, and, by extension, health/healthcare outcomes.2 Prior observational studies have supported some of these claims—for example, documenting that patients are overwhelmingly interested in and satisfied with receiving their healthcare data electronically,3 to finding that patients do identify cheap cipro pills errors when they read physician notes in the EHR.4 Because studies of EHR access for patients have been conducted and disseminated across disparate clinical conditions and settings and often using varied methodologies, the systematic review by Neves et al in this issue of BMJ Quality &. Safety provides a valuable contribution in assessing the impact of patients’ EHR access specifically within the randomised controlled trial (RCT) literature.5 Their meta-analysis demonstrates some significant but potentially limited benefits within these 20 RCTs that involved sharing EHR data/access with patients.Overall, Neves et al found a few clear trends.

First, there was a consistent, modest improvement in glycaemic control in RCTs targeting patients with diabetes, reinforcing the observational research focused on portal use for diabetes care.6 In addition, patient access to EHRs seemed to support safety of care in facilitating medication adherence and identification of medication discrepancies cheap cipro pills. These results are similar to observational studies,7 as well as cheap cipro pills a recent scoping review of patient engagement interventions to promote the safety of care and to improve short-term and intermediate-term clinical outcomes.8 Finally, for patient-reported outcomes ranging from self-efficacy to patient activation to patient satisfaction, results were mixed, with about half of included studies showing some improvement. Thus, this review highlighted a wide variation and potential lack of consensus about what patient-centred outcome to include in studying EHR-enabled interventions, given the diffuse set of behaviours that could be targeted.

More importantly, this review highlights that none of the included studies, many of which are older, focused on equity as a primary objective of the work (and very few even included data on racial/ethnic, educational attainment, digital literacy and/or health literacy differences9 10)—even though there are known barriers to digital health interventions by these characteristics.Despite the modest benefits seen in these 20 randomised trials of EHR-facilitated complex care interventions, we still believe cheap cipro pills in the clinical value and potential improvement in patient-reported outcomes in this space. A more careful examination of the 20 included studies in this review actually sheds important light on delivering complex interventions to improve quality of care, during which patient access to EHRs was implemented in varied ways that might have led to more muddled results. For example, many of the included studies tested cheap cipro pills evidence-based practices that are known to independently enhance the quality of care, such as patient outreach and reminders for healthcare tasks, self-management training and increased healthcare provider communication access.

Therefore, without detailed behavioural pathways for the targeted intervention components surrounding EHR data access, it is challenging to cheap cipro pills interpret observed trial effects. In our opinion and in our previous work,11 one-time action by systems or clinics granting patient access to EHRs is unlikely to replicate the effect of these interventions. In particular, access versus training to cheap cipro pills use EHRs should likely be considered separately, as well as the study of specific features within the EHR.

For example, passive provision of medical information from the EHR via online portals (eg, after-visit summaries or list of immunisations) differs substantially from active communication or completion of healthcare tasks via EHR-linked websites (eg, secure messaging exchanges between patients and providers about medical concerns or medication refill requests).Therefore, we hope that this review can push the field beyond RCTs of patient access to EHR data and into specific mechanisms for patient uptake/use that could be more generalisable. First and foremost, it is now generally accepted that patients have the right to view their own cheap cipro pills health data, both because of their ownership of that information and the convenience it may offer. This indicates that it will likely be impossible to randomise patients to either receive or not cheap cipro pills receive EHR data in the future, and interventions surrounding universal EHR data access could be more specific to targeted behaviours.

For example, now that patient electronic access to data is here to stay, future attention to research methods that tailor interventions, tease apart core implementation strategies, and engage patients and providers in codesign will be important next steps to ensure efficiency and relevance. Finally, and perhaps most importantly, RCT participants often differ significantly from target populations, with volunteers cheap cipro pills often exhibiting higher educational attainment and less racial/ethnic diversity.12 Given known disparities in patient EHR access by race/ethnicity, socioeconomic status and health literacy mentioned previously, these trials are not likely to generalise to more diverse populations.Moving forward, the results of this review highlight several principles for future studies of technology-facilitated healthcare delivery. First, all studies need to both include diverse participants and report on race, ethnicity, educational attainment, and health and digital literacy.13 Second, future work must focus on both internal and external validity of patient access/use of EHR data.

The review by Neves et al gives us some clearer understanding of the internal validity of studies on clinical and patient-reported outcomes, but it remains unclear what impact these types of interventions will have on health outcomes across an entire healthcare system or region outside of cheap cipro pills RCT samples. Studies of patient EHR access/use can move into the external validity space (even while conducting RCTs)14 by including implementation outcomes, such as the proportion of individuals offered EHR access who take it up, the extent of use over time, the type/features used, and costs for providers and staff, in addition to effectiveness in promoting health outcomes and differences across socioeconomic status, racial/ethnic groups and literacy levels.Like patient advocates and experts for many cheap cipro pills years, we absolutely agree that patient records belong to patients and should be readily available in structured, electronic form for patients and families.15 Given the complexity of the information provided and the specific context for interacting or supporting patients in completing tasks via online patient portals/platforms, we should not expect access alone to ameliorate current gaps in care or significantly improve morbidity and mortality. As more care becomes digital-first (ie, with virtual care and telemedicine), there are real concerns about widening healthcare disparities for low-income, racial–ethnic minority and linguistically diverse populations.

Our specific recommendations to avoid such undesirable developments moving forward includeWider measurement of patient interest and access/skills to using technology-based health platforms and tools.Tailoring of interventions to match cheap cipro pills patient preferences and needs, such as by digital literacy skills as well as inclusion of caregivers/families to support use.Use of mixed method and implementation science studies to understand use, usability, and uptake alongside clinical impact and effectiveness.Attention to these points will allow us to understand the ways in which patient portals and other forms of EHR access for patients may produce different impacts across distinct patient groups. This understanding will not only mitigate potential adverse effects for vulnerable groups but also achieve the intended goal of improving healthcare quality for all patients through freer access to information about their care..

Cipro online usa

How to cite this article:Singh OP cipro online usa. Psychiatry research in India. Closing the research cipro online usa gap.

Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science. Research in India in general and medical research in particular is always being criticized for lack of innovation and originality required for the delivery of health services cipro online usa suitable to Indian conditions. Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism.

It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up cipro online usa to the mark and is not commensurate with the magnitude of the disease burden in India. According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases.

The research conducted elsewhere may not be generalized to the Indian population owing to differences in biology, health-care systems, health practices, cipro online usa culture, and socioeconomic standards. Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017–2018) of the Department of Health Research observed that “the biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.”[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research.

While ICMR has a budget of 232 million dollars per year on health research, it is zilch in comparison to the annual budget expenditure of the National Institute of Health, cipro online usa USA, on biomedical research which is 32 billion dollars.The lacuna of quality research is not merely due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and cipro online usa resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical institutions.

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

PGIMER, Chandigarh. CMC, Vellore cipro online usa. And SGIMS, Lucknow are among the top ten medical institutions in terms of publication in peer-reviewed journals, around 332 (57.3%) medical colleges have no research paper published in a decade between 2004 and 2014.[2]The research in psychiatry is realistically dominated by major research institutes which are doing commendable work, but there is a substantial lack of contemporary research originating from other centers.

Dr. Chittaranjan Andrade (NIMHANS, Bengaluru) and Dr. K Jacob (CMC, Vellore) recently figured in the list of top 2% psychiatry researchers in the world from India in psychiatry.[3] Most of the research conducted in the field of psychiatry are limited to caregivers' burden, pathways of care, and other topics which can be done in limited resources available to psychiatry departments.

While all these areas of work are important in providing proper care and treatment, there is overabundance of research in these areas.The Government of India is aggressively looking forward to enhancing the quality of research and is embarking on an ambitious project of purchasing all major journals and providing free access to universities across the country. The India Genome Project started in January, 2020, is a good example of collaboration. While all these actions are laudable, a lot more needs to be done.

Following are some measures which will reduce the gap:Research proposals at the level of protocol can be guided and mentored by institutes. Academic committees of different zones and journals can help in this endeavorBreaking the cubicles by establishing a collaboration between medical colleges and various institutes. While there is a lack of resources available in individual departments, there are universities and institutes with excellent infrastructure.

They are not aware of the requirements of the field of psychiatry and research questions. Creation of an alliance will enhance the quality of research work. Some of such institutes include Centre for Neuroscience, Indian Institute of Science, Bengaluru.

CSIR-Institute of Genomics and Integrative Biology, New Delhi. And National Institute of Biomedical Genomics, KalyaniInitiation and establishment of interactive and stable relationships between basic scientists and clinical and technological experts will enhance the quality of research work and will lead to translation of basic biomedical research into real-time applications. For example, work on artificial intelligence for mental health.

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

References 1.2.Nagoba B, Davane M. Current status of medical research in India. Where are we?.

Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J. Updated science-wide author databases of standardized citation indicators.

PLoS Biol 2020;18:e3000918. Correspondence Address:Dr. Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1362_2Abstract Background.

The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly.Aim. The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research.Materials and Methods. Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis.

PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies. Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme. Studies were summarized and reported descriptively.Results.

Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas. Alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services.

Sociocultural factors play a major role in understanding and determining mental disorders.Conclusion. This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality.

Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.Keywords. India, mental health, scheduled tribesHow to cite this article:Devarapalli S V, Kallakuri S, Salam A, Maulik PK. Mental health research on scheduled tribes in India.

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

In northeastern states, they constitute 65% or more of the total population.[5] The ST communities are identified as culturally or ethnographically unique by the Indian Constitution. They are populations with poorer health indicators and fewer health-care facilities compared to non-ST rural populations, even when within the same state, and often live in demarcated geographical areas known as ST areas.[4]As per the National Family Health Survey, 2015–2016, the health indicators such as infant mortality rate (IMR) is 44.4, under five mortality rate (U5MR) is 57.2, and anemia in women is 59.8 for STs – one of the most disadvantaged socioeconomic groups in India, which are worse compared to other populations where IMR is 40.7, U5MR is 49.7, and anemia in women among others is 53.0 in the same areas.[6] Little research is available on the health of ST population. Tribal mental health is an ignored and neglected area in the field of health-care services.

Further, little data are available about the burden of mental disorders among the tribal communities. Health research on tribal populations is poor, globally.[7] Irrespective of the data available, it is clear that they have worse health indicators and less access to health facilities.[8] Even less is known about the burden of mental disorders in ST population. It is also found that the traditional livelihood system of the STs came into conflict with the forces of modernization, resulting not only in the loss of customary rights over the livelihood resources but also in subordination and further, developing low self-esteem, causing great psychological stress.[4] This community has poor health infrastructure and even less mental health resources, and the situation is worse when compared to other communities living in similar areas.[9],[10]Only 15%–25% of those affected with mental disorders in LMICs receive any treatment for their mental illness,[11] resulting in a large “treatment gap.”[12] Treatment gaps are more in rural populations,[13] especially in ST communities in India, which have particularly poor infrastructure and resources for health-care delivery in general, and almost no capacity for providing mental health care.[14]The aim of this systematic review was to explore the extent and nature of mental health research on ST population in India and to identify gaps and inform future research.

Materials and Methods Search strategyWe searched major databases (PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar) and made hand searches from January 1980 to December 2018 to identify relevant literature. Hand search refers to searching through medical journals which are not indexed in the major electronic databases such as Embase, for instance, searching for Indian journals in IndMed database as most of these journals are not available in major databases. Physical search refers to searching the journals that were not available online or were not available online during the study years.

We used relevant Medical Subject Heading and key terms in our search strategy, as follows. €œMental health,” “Mental disorders,” “Mental illness,” “Psychiatry,” “Scheduled Tribe” OR “Tribe” OR “Tribal Population” OR “Indigenous population,” “India,” “Psych*” (Psychiatric, psychological, psychosis).Inclusion criteriaStudies published between January 1980 and December 2018 were included. Studies on mental disorders were included only when they focused on ST population.

Both qualitative and quantitative studies on mental disorders of ST population only were included in the analysis.Exclusion criteriaStudies without any primary data and which are merely overviews and commentaries and those not focused on ST population were excluded from the analysis.Data management and analysisTwo researchers (SD and SK) initially screened the title and abstract of each record to identify relevant papers and subsequently screened full text of those relevant papers. Any disagreements between the researchers were resolved by discussion or by consulting with an adjudicator (PKM). From each study, data were extracted on objectives, study design, study population, study duration, interventions (if applicable), outcomes, and results.

Quality of the included studies was assessed, independently by three researchers (SD, SK, and AS), using Critical Appraisal Checklist developed by Critical Appraisal Skills Programme (CASP).[15] After a thorough qualitative assessment, all quantitative data were generated and tabulated. A narrative description of the studies is provided in [Table 1] using some broad categories. Results Search resultsOur search retrieved 2306 records (which included hand-searched articles), of which after removing duplicates, title and abstracts of 2278 records were screened.

Of these, 178 studies were deemed as potentially relevant and were reviewed in detail. Finally, we excluded 146 irrelevant studies and 32 studies were included in the review [Figure 1].Quality of the included studiesSummary of quality assessment of the included studies is reported in [Table 2]. Overall, nine studies were of poor quality, twenty were of moderate quality, and three studies were of high quality.

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

Nonresponse not addressed. Risk factors not measured correctly. And methods used were not sufficiently described to repeat them.

Studies under the moderate quality did not have a representative sample. Non-responders categories was not addressed. Risk factors were not measured correctly.

And methods used were not sufficiently described to allow the study to be replicated by other researchers.The included studies covered three broad categories. Alcohol and substance use disorders, CMD (depression, anxiety, stress, and suicide risk), socio-cultural aspects, and access to mental health services.Alcohol and substance use disordersFive studies reviewed the consumption of alcohol and opioid. In an ethnographic study conducted in three western districts in Rajasthan, 200 opium users were interviewed.

Opium consumption was common among both younger and older males during nonharvest seasons. The common causes for using opium were relief of anxiety related to crop failure due to drought, stress, to get a high, be part of peers, and for increased sexual performance.[16]In a study conducted in Arunachal Pradesh involving a population of more than 5000 individuals, alcohol use was present in 30% and opium use in about 5% adults.[17] Contrary to that study, in Rajasthan, the prevalence of opium use was more in women and socioeconomic factors such as occupation, education, and marital status were associated with opium use.[16] The prevalence of opium use increased with age in both sexes, decreased with increasing education level, and increased with employment. It was observed that wages were used to buy opium.

In the entire region of Chamlang district of Arunachal Pradesh, female substance users were almost half of the males among ST population.[17] Types of substance used were tobacco, alcohol, and opium. Among tobacco users, oral tobacco use was higher than smoking. The prevalence of tobacco use was higher among males, but the prevalence of alcohol use was higher in females, probably due to increased access to homemade rice brew generally prepared by women.

This study is unique in terms of finding a strong association with religion and culture with substance use.[18]Alcohol consumption among Paniyas of Wayanad district in Kerala is perceived as a male activity, with many younger people consuming it than earlier. A study concluded that alcohol consumption among them was less of a “choice” than a result of their conditions operating through different mechanisms. In the past, drinking was traditionally common among elderly males, however the consumption pattern has changed as a significant number of younger men are now drinking.

Drinking was clustered within families as fathers and sons drank together. Alcohol is easily accessible as government itself provides opportunities. Some employers would provide alcohol as an incentive to attract Paniya men to work for them.[19]In a study from Jharkhand, several ST community members cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol.

Societal acceptance of drinking alcohol and peer pressure, as well as high emotional problems, appeared to be the major etiology leading to higher prevalence of substance dependence in tribal communities.[20] Another study found high life time alcohol use prevalence, and the reasons mentioned were increased poverty, illiteracy, increased stress, and peer pressure.[21] A household survey from Chamlang district of Arunachal Pradesh revealed that there was a strong association between opium use and age, occupation, marital status, religion, and ethnicity among both the sexes of STs, particularly among Singhpho and Khamti.[15] The average age of onset of tobacco use was found to be 16.4 years for smoked and 17.5 years for smokeless forms in one study.[22]Common mental disorders and socio-cultural aspectsSuicide was more common among Idu Mishmi in Roing and Anini districts of Arunachal Pradesh state (14.2%) compared to the urban population in general (0.4%–4.2%). Suicides were associated with depression, anxiety, alcoholism, and eating disorders. Of all the factors, depression was significantly high in people who attempted suicide.[24] About 5% out of 5007 people from thirty villages comprising ST suffered from CMDs in a study from West Godavari district in rural Andhra Pradesh.

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

The study found that among the three factors namely stress, marital status, and ethnicity, ethnicity was found to affect mental health of the school teachers most. It found a positive relationship between mental health and socioeconomic status, with an inverse relationship showing that as income increased, the prevalence of depression decreased.[28] A study among Ao-Nagas in Nagaland found that 74.6% of the population attributed mental health problems to psycho-social factors and a considerable proportion chose a psychiatrist or psychologist to overcome the problem. However, 15.4% attributed mental disorders to evil spirits.

About 47% preferred to seek treatment with a psychiatrist and 25% preferred prayers. Nearly 10.6% wanted to seek the help of both the psychiatrist and prayer group and 4.4% preferred traditional healers.[28],[29] The prevalence of Down syndrome among the ST in Chikhalia in Barwani district of Madhya Pradesh was higher than that reported in overall India. Three-fourth of the children were the first-born child.

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

The key objectives were to use task sharing, training of primary health workers, implementing evidence-based clinical decision support tools on a mobile platform, and providing mental health services to rural population. The study included 238 adults suffering from CMD. During the intervention period, 12.6% visited the primary health-care doctors compared to only 0.8% who had sought any care for their mental disorders prior to the intervention.

The study also found a significant reduction in the depression and anxiety scores at the end of intervention and improvements in stigma perceptions related to mental health.[14] A study in Gudalur and Pandalur Taluks of Nilgiri district from Tamil Nadu used low cost task shifting by providing community education and identifying and referring individuals with psychiatric problems as effective strategies for treating mental disorders in ST communities. Through the program, the health workers established a network within the village, which in turn helped the patients to interact with them freely. Consenting patients volunteered at the educational sessions to discuss their experience about the effectiveness of their treatment.

Community awareness programs altered knowledge and attitudes toward mental illness in the community.[33] A study in Nilgiri district, Tamil Nadu, found that the community had been taking responsibility of the patients with the system by providing treatment closer to home without people having to travel long distances to access care. Expenses were reduced by subsidizing the costs of medicine and ensuring free hospital admissions and referrals to the people.[34] A study on the impact of gender, socioeconomic status, and age on mental health of female factory workers in Jharkhand found that the ST women were more likely to face stress and hardship in life due to diverse economic and household responsibilities, which, in turn, severely affected their mental health.[35] Prevalence of mental health morbidity in a study from the Sunderbans delta found a positive relation with psycho-social stressors and poor quality of life. The health system in that remote area was largely managed by “quack doctors” and faith healers.

Poverty, illiteracy, and detachment from the larger community helped reinforce superstitious beliefs and made them seek both mental and physical health care from faith healers.[36] In a study among students, it was found that children had difficulties in adjusting to both ethnic and mainstream culture.[27] Low family income, inadequate housing, poor sanitation, and unhealthy and unhygienic living conditions were some environmental factors contributing to poor physical and mental growth of children. It was observed that children who did not have such risk factors maintained more intimate relations with the family members. Children belonging to the disadvantaged environment expressed their verbal, emotional need, blame, and harm avoidances more freely than their counterparts belonging to less disadvantaged backgrounds.

Although disadvantaged children had poor interfamilial interaction, they had better relations with the members outside family, such as peers, friends, and neighbors.[37] Another study in Jharkhand found that epilepsy was higher among ST patients compared to non-ST patients.[31] Most patients among the ST are irregular and dropout rates are higher among them than the non-ST patients. Urbanization per se exerted no adverse influence on the mental health of a tribal community, provided it allowed preservation of ethnic and cultural practices. Women in the ST communities were less vulnerable to mental illness than men.

This might be a reflection of their increased responsibilities and enhanced gender roles that are characteristic of women in many ST communities.[38] Data obtained using culturally relevant scales revealed that relocated Sahariya suffer a lot of mental health problems, which are partially explained by livelihood and poverty-related factors. The loss of homes and displacement compromise mental health, especially the positive emotional well-being related to happiness, life satisfaction, optimism for future, and spiritual contentment. These are often not overcome even with good relocation programs focused on material compensation and livelihood re-establishment.[39] Discussion This systematic review is to our knowledge the first on mental health of ST population in India.

Few studies on the mental health of ST were available. All attempts including hand searching were made to recover both published peer-reviewed papers and reports available on the website. Though we searched gray literature, it may be possible that it does not capture all articles.

Given the heterogeneity of the papers, it was not possible to do a meta-analysis, so a narrative review was done.The quality of the studies was assessed by CASP. The assessment shows that the research conducted on mental health of STs needs to be carried out more effectively. The above mentioned gaps need to be filled in future research by considering the resources effectively while conducting the studies.

Mental and substance use disorders contribute majorly to the health disparities. To address this, one needs to deliver evidence-based treatments, but it is important to understand how far these interventions for the indigenous populations can incorporate cultural practices, which are essential for the development of mental health services.[30] Evidence has shown a disproportionate burden of suicide among indigenous populations in national and regional studies, and a global and systematic investigation of this topic has not been undertaken to date. Previous reviews of suicide epidemiology among indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth, high-income countries, or regions such as Oceania or the Arctic.[46] The only studies in our review which provided data on suicide were in Idu Mishmi, an isolated tribal population of North-East India, and tribal communities from Sunderban delta.[24],[37] Some reasons for suicide in these populations could be the poor identification of existing mental disorders, increased alcohol use, extreme poverty leading to increased debt and hopelessness, and lack of stable employment opportunities.[24],[37] The traditional consumption pattern of alcohol has changed due to the reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement.[19],[20]Faith healers play a dominant role in treating mental disorders.

There is less awareness about mental health and available mental health services and even if such knowledge is available, access is limited due to remoteness of many of these villages, and often it involves high out-of-pocket expenditure.[35] Practitioners of modern medicine can play a vital role in not only increasing awareness about mental health in the community, but also engaging with faith healers and traditional medicine practitioners to help increase their capacity to identify and manage CMDs that do not need medications and can be managed through simple “talk therapy.” Knowledge on symptoms of severe mental disorders can also help such faith healers and traditional medicine practitioners to refer cases to primary care doctors or mental health professionals.Remote settlements make it difficult for ST communities to seek mental health care. Access needs to be increased by using solutions that use training of primary health workers and nonphysician health workers, task sharing, and technology-enabled clinical decision support tools.[3] The SMART Mental Health project was delivered in the tribal areas of Andhra Pradesh using those principles and was found to be beneficial by all stakeholders.[14]Given the lack of knowledge about mental health problems among these communities, the government and nongovernmental organizations should collect and disseminate data on mental disorders among the ST communities. More research funding needs to be provided and key stakeholders should be involved in creating awareness both in the community and among policy makers to develop more projects for ST communities around mental health.

Two recent meetings on tribal mental health – Round Table Meeting on Mental Health of ST Populations organized by the George Institute for Global Health, India, in 2017,[51] and the First National Conference on Tribal Mental Health organized by the Indian Psychiatric Society in Bhubaneswar in 2018 – have identified some key areas of research priority for mental health in ST communities. A national-level policy on mental health of tribal communities or population is advocated which should be developed in consultation with key stakeholders. The Indian Psychiatric Society can play a role in coordinating research activities with support of the government which can ensure regular monitoring and dissemination of the research impact to the tribal communities.

There is a need to understand how mental health symptoms are perceived in different ST communities and investigate the healing practices associated with distress/disaster/death/loss/disease. This could be done in the form of cross-sectional or cohort studies to generate proper evidence which could also include the information on prevalence, mental health morbidity, and any specific patterns associated with a specific disorder. Future research should estimate the prevalence of mental disorders in different age groups and gender, risk factors, and the influence of modernization.

Studies should develop a theoretical model to understand mental disorders and promote positive mental health within ST communities. Studies should also look at different ST communities as cultural differences exist across them, and there are also differences in socioeconomic status which impact on ability to access care.Research has shown that the impact and the benefits are amplified when research is driven by priorities that are identified by indigenous communities and involve their active participation. Their knowledge and perspectives are incorporated in processes and findings.

Reporting of findings is meaningful to the communities. And indigenous groups and other key stakeholders are engaged from the outset.[47] Future research in India on ST communities should also adhere to these broad principles to ensure relevant and beneficial research, which have direct impact on the mental health of the ST communities.There is also a need to update literature related to mental health of ST population continuously. Develop culturally appropriate validated instruments to measure mental morbidity relevant to ST population.

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

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Oral Hygiene and Health 2016;4:1 23.Manimunda SP, Benegal V, Sugunan AP, Jeemon P, Balakrishna N, Thennarusu K, et al. Tobacco use and nicotine dependency in a cross-sectional representative sample of 18,018 individuals in Andaman and Nicobar Islands, India. BMC Public Health 2012;12:515.

24.Singh PK, Singh RK, Biswas A, Rao VR. High rate of suicide attempt and associated psychological traits in an isolated tribal population of North-East India. J Affect Dis 2013;151:673-8.

25.Sushila J. Perception of Illness and Health Care among Bhils. A Study of Udaipur District in Southern Rajasthan.

2005. 26.Sobhanjan S, Mukhopadhyay B. Perceived psychosocial stress and cardiovascular risk.

Observations among the Bhutias of Sikkim, India. Stress Health 2008;24:23-34. 27.Ali A, Eqbal S.

Mental Health status of tribal school going adolescents. A study from rural community of Ranchi, Jharkhand. Telangana J Psychiatry 2016;2:38-41.

28.Diwan R. Stress and mental health of tribal and non tribal female school teachers in Jharkhand, India. Int J Sci Res Publicat 2012;2:2250-3153.

29.Longkumer I, Borooah PI. Knowledge about attitudes toward mental disorders among Nagas in North East India. IOSR J Humanities Soc Sci 2013;15:41-7.

30.Lakhan R, Kishore MT. Down syndrome in tribal population in India. A field observation.

J Neurosci Rural Pract 2016;7:40-3. [PUBMED] [Full text] 31.Nizamie HS, Akhtar S, Banerjee S, Goyal N. Health care delivery model in epilepsy to reduce treatment gap.

WHO study from a rural tribal population of India. Epilepsy Res Elsevier 2009;84:146-52. 32.Prabhakar H, Manoharan R.

The Tribal Health Initiative model for healthcare delivery. A clinical and epidemiological approach. Natl Med J India 2005;18:197-204.

33.Nimgaonkar AU, Menon SD. A task shifting mental health program for an impoverished rural Indian community. Asian J Psychiatr 2015;16:41-7.

34.Yalsangi M. Evaluation of a Community Mental Health Programme in a Tribal Area- South India. Achutha Menon Centre For Health Sciences Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Working Paper No 12.

2012. 35.Tripathy P, Nirmala N, Sarah B, Rajendra M, Josephine B, Shibanand R, et al. Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India.

A cluster-randomised controlled trial. Lancet 2010;375:1182-92. 36.Aparajita C, Anita KM, Arundhati R, Chetana P.

Assessing Social-support network among the socio culturally disadvantaged children in India. Early Child Develop Care 1996;121:37-47. 37.Chowdhury AN, Mondal R, Brahma A, Biswas MK.

Eco-psychiatry and environmental conservation. Study from Sundarban Delta, India. Environ Health Insights 2008;2:61-76.

38.Jeffery GS, Chakrapani U. Eco-psychiatry and Environmental Conservation. Study from Sundarban Delta, India.

Working Paper- Research Gate.net. September, 2016. 39.Ozer S, Acculturation, adaptation, and mental health among Ladakhi College Students a mixed methods study of an indigenous population.

J Cross Cultl Psychol 2015;46:435-53. 40.Giri DK, Chaudhary S, Govinda M, Banerjee A, Mahto AK, Chakravorty PK. Utilization of psychiatric services by tribal population of Jharkhand through community outreach programme of RINPAS.

Eastern J Psychiatry 2007;10:25-9. 41.Nandi DN, Banerjee G, Chowdhury AN, Banerjee T, Boral GC, Sen B. Urbanization and mental morbidity in certain tribal communities in West Bengal.

Indian J Psychiatry 1992;34:334-9. [PUBMED] [Full text] 42.Hackett RJ, Sagdeo D, Creed FH. The physical and social associations of common mental disorder in a tribal population in South India.

Soc Psychiatry Psychiatr Epidemiol 2007;42:712-5. 43.Raina SK, Raina S, Chander V, Grover A, Singh S, Bhardwaj A. Development of a cognitive screening instrument for tribal elderly population of Himalayan region in northern India.

J Neurosci Rural Pract 2013;4:147-53. [PUBMED] [Full text] 44.Raina SK, Raina S, Chander V, Grover A, Singh S, Bhardwaj A. Identifying risk for dementia across populations.

A study on the prevalence of dementia in tribal elderly population of Himalayan region in Northern India. Ann Indian Acad Neurol 2013;16:640-4. [PUBMED] [Full text] 45.Raina SK, Chander V, Raina S, Kumar D.

Feasibility of using everyday abilities scale of India as alternative to mental state examination as a screen in two-phase survey estimating the prevalence of dementia in largely illiterate Indian population. Indian J Psychiatry 2016;58:459-61. [PUBMED] [Full text] 46.Diwan R.

Mental health of tribal male-female factory workers in Jharkhand. IJAIR 2012;2278:234-42. 47.Banerjee T, Mukherjee SP, Nandi DN, Banerjee G, Mukherjee A, Sen B, et al.

Psychiatric morbidity in an urbanized tribal (Santal) community - A field survey. Indian J Psychiatry 1986;28:243-8. [PUBMED] [Full text] 48.Leske S, Harris MG, Charlson FJ, Ferrari AJ, Baxter AJ, Logan JM, et al.

Systematic review of interventions for Indigenous adults with mental and substance use disorders in Australia, Canada, New Zealand and the United States. Aust N Z J Psychiatry 2016;50:1040-54. 49.Pollock NJ, Naicker K, Loro A, Mulay S, Colman I.

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50.Silburn K, et al. Evaluation of the Cooperative Research Centre for Aboriginal Health (Australian institute for primary care, trans.). Melbourne.

Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].

How to cite this cheap cipro pills article:Singh OP. Psychiatry research in India. Closing the cheap cipro pills research gap.

Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science. Research in India in general and medical research in particular is always being criticized for lack of innovation and originality required for the delivery of cheap cipro pills health services suitable to Indian conditions. Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism.

It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or even cheap cipro pills one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up to the mark and is not commensurate with the magnitude of the disease burden in India. According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases.

The research conducted elsewhere may not be generalized to the Indian population owing to differences in biology, health-care systems, health practices, cheap cipro pills culture, and socioeconomic standards. Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017–2018) of the Department of Health Research observed that “the biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.”[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research.

While ICMR has a budget of 232 million dollars per year on health research, it is zilch in comparison to the annual budget expenditure of the National Institute of Health, USA, on biomedical research which is 32 billion dollars.The lacuna of quality research is not merely cheap cipro pills due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due cheap cipro pills to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical institutions.

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

PGIMER, Chandigarh. CMC, Vellore cheap cipro pills. And SGIMS, Lucknow are among the top ten medical institutions in terms of publication in peer-reviewed journals, around 332 (57.3%) medical colleges have no research paper published in a decade between 2004 and 2014.[2]The research in psychiatry is realistically dominated by major research institutes which are doing commendable work, but there is a substantial lack of contemporary research originating from other centers.

Dr. Chittaranjan Andrade (NIMHANS, Bengaluru) and Dr. K Jacob (CMC, Vellore) recently figured in the list of top 2% psychiatry researchers in the world from India in psychiatry.[3] Most of the research conducted in the field of psychiatry are limited to caregivers' burden, pathways of care, and other topics which can be done in limited resources available to psychiatry departments.

While all these areas of work are important in providing proper care and treatment, there is overabundance of research in these areas.The Government of India is aggressively looking forward to enhancing the quality of research and is embarking on an ambitious project of purchasing all major journals and providing free access to universities across the country. The India Genome Project started in January, 2020, is a good example of collaboration. While all these actions are laudable, a lot more needs to be done.

Following are some measures which will reduce the gap:Research proposals at the level of protocol can be guided and mentored by institutes. Academic committees of different zones and journals can help in this endeavorBreaking the cubicles by establishing a collaboration between medical colleges and various institutes. While there is a lack of resources available in individual departments, there are universities and institutes with excellent infrastructure.

They are not aware of the requirements of the field of psychiatry and research questions. Creation of an alliance will enhance the quality of research work. Some of such institutes include Centre for Neuroscience, Indian Institute of Science, Bengaluru.

CSIR-Institute of Genomics and Integrative Biology, New Delhi. And National Institute of Biomedical Genomics, KalyaniInitiation and establishment of interactive and stable relationships between basic scientists and clinical and technological experts will enhance the quality of research work and will lead to translation of basic biomedical research into real-time applications. For example, work on artificial intelligence for mental health.

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

References 1.2.Nagoba B, Davane M. Current status of medical research in India. Where are we?.

Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J. Updated science-wide author databases of standardized citation indicators.

PLoS Biol 2020;18:e3000918. Correspondence Address:Dr. Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1362_2Abstract Background.

The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly.Aim. The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research.Materials and Methods. Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis.

PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies. Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme. Studies were summarized and reported descriptively.Results.

Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas. Alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services.

Sociocultural factors play a major role in understanding and determining mental disorders.Conclusion. This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality.

Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.Keywords. India, mental health, scheduled tribesHow to cite this article:Devarapalli S V, Kallakuri S, Salam A, Maulik PK. Mental health research on scheduled tribes in India.

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

In northeastern states, they constitute 65% or more of the total population.[5] The ST communities are identified as culturally or ethnographically unique by the Indian Constitution. They are populations with poorer health indicators and fewer health-care facilities compared to non-ST rural populations, even when within the same state, and often live in demarcated geographical areas known as ST areas.[4]As per the National Family Health Survey, 2015–2016, the health indicators such as infant mortality rate (IMR) is 44.4, under five mortality rate (U5MR) is 57.2, and anemia in women is 59.8 for STs – one of the most disadvantaged socioeconomic groups in India, which are worse compared to other populations where IMR is 40.7, U5MR is 49.7, and anemia in women among others is 53.0 in the same areas.[6] Little research is available on the health of ST population. Tribal mental health is an ignored and neglected area in the field of health-care services.

Further, little data are available about the burden of mental disorders among the tribal communities. Health research on tribal populations is poor, globally.[7] Irrespective of the data available, it is clear that they have worse health indicators and less access to health facilities.[8] Even less is known about the burden of mental disorders in ST population. It is also found that the traditional livelihood system of the STs came into conflict with the forces of modernization, resulting not only in the loss of customary rights over the livelihood resources but also in subordination and further, developing low self-esteem, causing great psychological stress.[4] This community has poor health infrastructure and even less mental health resources, and the situation is worse when compared to other communities living in similar areas.[9],[10]Only 15%–25% of those affected with mental disorders in LMICs receive any treatment for their mental illness,[11] resulting in a large “treatment gap.”[12] Treatment gaps are more in rural populations,[13] especially in ST communities in India, which have particularly poor infrastructure and resources for health-care delivery in general, and almost no capacity for providing mental health care.[14]The aim of this systematic review was to explore the extent and nature of mental health research on ST population in India and to identify gaps and inform future research.

Materials and Methods Search strategyWe searched major databases (PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar) and made hand searches from January 1980 to December 2018 to identify relevant literature. Hand search refers to searching through medical journals which are not indexed in the major electronic databases such as Embase, for instance, searching for Indian journals in IndMed database as most of these journals are not available in major databases. Physical search refers to searching the journals that were not available online or were not available online during the study years.

We used relevant Medical Subject Heading and key terms in our search strategy, as follows. €œMental health,” “Mental disorders,” “Mental illness,” “Psychiatry,” “Scheduled Tribe” OR “Tribe” OR “Tribal Population” OR “Indigenous population,” “India,” “Psych*” (Psychiatric, psychological, psychosis).Inclusion criteriaStudies published between January 1980 and December 2018 were included. Studies on mental disorders were included only when they focused on ST population.

Both qualitative and quantitative studies on mental disorders of ST population only were included in the analysis.Exclusion criteriaStudies without any primary data and which are merely overviews and commentaries and those not focused on ST population were excluded from the analysis.Data management and analysisTwo researchers (SD and SK) initially screened the title and abstract of each record to identify relevant papers and subsequently screened full text of those relevant papers. Any disagreements between the researchers were resolved by discussion or by consulting with an adjudicator (PKM). From each study, data were extracted on objectives, study design, study population, study duration, interventions (if applicable), outcomes, and results.

Quality of the included studies was assessed, independently by three researchers (SD, SK, and AS), using Critical Appraisal Checklist developed by Critical Appraisal Skills Programme (CASP).[15] After a thorough qualitative assessment, all quantitative data were generated and tabulated. A narrative description of the studies is provided in [Table 1] using some broad categories. Results Search resultsOur search retrieved 2306 records (which included hand-searched articles), of which after removing duplicates, title and abstracts of 2278 records were screened.

Of these, 178 studies were deemed as potentially relevant and were reviewed in detail. Finally, we excluded 146 irrelevant studies and 32 studies were included in the review [Figure 1].Quality of the included studiesSummary of quality assessment of the included studies is reported in [Table 2]. Overall, nine studies were of poor quality, twenty were of moderate quality, and three studies were of high quality.

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

Nonresponse not addressed. Risk factors not measured correctly. And methods used were not sufficiently described to repeat them.

Studies under the moderate quality did not have a representative sample. Non-responders categories was not addressed. Risk factors were not measured correctly.

And methods used were not sufficiently described to allow the study to be replicated by other researchers.The included studies covered three broad categories. Alcohol and substance use disorders, CMD (depression, anxiety, stress, and suicide risk), socio-cultural aspects, and access to mental health services.Alcohol and substance use disordersFive studies reviewed the consumption of alcohol and opioid. In an ethnographic study conducted in three western districts in Rajasthan, 200 opium users were interviewed.

Opium consumption was common among both younger and older males during nonharvest seasons. The common causes for using opium were relief of anxiety related to crop failure due to drought, stress, to get a high, be part of peers, and for increased sexual performance.[16]In a study conducted in Arunachal Pradesh involving a population of more than 5000 individuals, alcohol use was present in 30% and opium use in about 5% adults.[17] Contrary to that study, in Rajasthan, the prevalence of opium use was more in women and socioeconomic factors such as occupation, education, and marital status were associated with opium use.[16] The prevalence of opium use increased with age in both sexes, decreased with increasing education level, and increased with employment. It was observed that wages were used to buy opium.

In the entire region of Chamlang district of Arunachal Pradesh, female substance users were almost half of the males among ST population.[17] Types of substance used were tobacco, alcohol, and opium. Among tobacco users, oral tobacco use was higher than smoking. The prevalence of tobacco use was higher among males, but the prevalence of alcohol use was higher in females, probably due to increased access to homemade rice brew generally prepared by women.

This study is unique in terms of finding a strong association with religion and culture with substance use.[18]Alcohol consumption among Paniyas of Wayanad district in Kerala is perceived as a male activity, with many younger people consuming it than earlier. A study concluded that alcohol consumption among them was less of a “choice” than a result of their conditions operating through different mechanisms. In the past, drinking was traditionally common among elderly males, however the consumption pattern has changed as a significant number of younger men are now drinking.

Drinking was clustered within families as fathers and sons drank together. Alcohol is easily accessible as government itself provides opportunities. Some employers would provide alcohol as an incentive to attract Paniya men to work for them.[19]In a study from Jharkhand, several ST community members cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol.

Societal acceptance of drinking alcohol and peer pressure, as well as high emotional problems, appeared to be the major etiology leading to higher prevalence of substance dependence in tribal communities.[20] Another study found high life time alcohol use prevalence, and the reasons mentioned were increased poverty, illiteracy, increased stress, and peer pressure.[21] A household survey from Chamlang district of Arunachal Pradesh revealed that there was a strong association between opium use and age, occupation, marital status, religion, and ethnicity among both the sexes of STs, particularly among Singhpho and Khamti.[15] The average age of onset of tobacco use was found to be 16.4 years for smoked and 17.5 years for smokeless forms in one study.[22]Common mental disorders and socio-cultural aspectsSuicide was more common among Idu Mishmi in Roing and Anini districts of Arunachal Pradesh state (14.2%) compared to the urban population in general (0.4%–4.2%). Suicides were associated with depression, anxiety, alcoholism, and eating disorders. Of all the factors, depression was significantly high in people who attempted suicide.[24] About 5% out of 5007 people from thirty villages comprising ST suffered from CMDs in a study from West Godavari district in rural Andhra Pradesh.

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

The study found that among the three factors namely stress, marital status, and ethnicity, ethnicity was found to affect mental health of the school teachers most. It found a positive relationship between mental health and socioeconomic status, with an inverse relationship showing that as income increased, the prevalence of depression decreased.[28] A study among Ao-Nagas in Nagaland found that 74.6% of the population attributed mental health problems to psycho-social factors and a considerable proportion chose a psychiatrist or psychologist to overcome the problem. However, 15.4% attributed mental disorders to evil spirits.

About 47% preferred to seek treatment with a psychiatrist and 25% preferred prayers. Nearly 10.6% wanted to seek the help of both the psychiatrist and prayer group and 4.4% preferred traditional healers.[28],[29] The prevalence of Down syndrome among the ST in Chikhalia in Barwani district of Madhya Pradesh was higher than that reported in overall India. Three-fourth of the children were the first-born child.

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

The key objectives were to use task sharing, training of primary health workers, implementing evidence-based clinical decision support tools on a mobile platform, and providing mental health services to rural population. The study included 238 adults suffering from CMD. During the intervention period, 12.6% visited the primary health-care doctors compared to only 0.8% who had sought any care for their mental disorders prior to the intervention.

The study also found a significant reduction in the depression and anxiety scores at the end of intervention and improvements in stigma perceptions related to mental health.[14] A study in Gudalur and Pandalur Taluks of Nilgiri district from Tamil Nadu used low cost task shifting by providing community education and identifying and referring individuals with psychiatric problems as effective strategies for treating mental disorders in ST communities. Through the program, the health workers established a network within the village, which in turn helped the patients to interact with them freely. Consenting patients volunteered at the educational sessions to discuss their experience about the effectiveness of their treatment.

Community awareness programs altered knowledge and attitudes toward mental illness in the community.[33] A study in Nilgiri district, Tamil Nadu, found that the community had been taking responsibility of the patients with the system by providing treatment closer to home without people having to travel long distances to access care. Expenses were reduced by subsidizing the costs of medicine and ensuring free hospital admissions and referrals to the people.[34] A study on the impact of gender, socioeconomic status, and age on mental health of female factory workers in Jharkhand found that the ST women were more likely to face stress and hardship in life due to diverse economic and household responsibilities, which, in turn, severely affected their mental health.[35] Prevalence of mental health morbidity in a study from the Sunderbans delta found a positive relation with psycho-social stressors and poor quality of life. The health system in that remote area was largely managed by “quack doctors” and faith healers.

Poverty, illiteracy, and detachment from the larger community helped reinforce superstitious beliefs and made them seek both mental and physical health care from faith healers.[36] In a study among students, it was found that children had difficulties in adjusting to both ethnic and mainstream culture.[27] Low family income, inadequate housing, poor sanitation, and unhealthy and unhygienic living conditions were some environmental factors contributing to poor physical and mental growth of children. It was observed that children who did not have such risk factors maintained more intimate relations with the family members. Children belonging to the disadvantaged environment expressed their verbal, emotional need, blame, and harm avoidances more freely than their counterparts belonging to less disadvantaged backgrounds.

Although disadvantaged children had poor interfamilial interaction, they had better relations with the members outside family, such as peers, friends, and neighbors.[37] Another study in Jharkhand found that epilepsy was higher among ST patients compared to non-ST patients.[31] Most patients among the ST are irregular and dropout rates are higher among them than the non-ST patients. Urbanization per se exerted no adverse influence on the mental health of a tribal community, provided it allowed preservation of ethnic and cultural practices. Women in the ST communities were less vulnerable to mental illness than men.

This might be a reflection of their increased responsibilities and enhanced gender roles that are characteristic of women in many ST communities.[38] Data obtained using culturally relevant scales revealed that relocated Sahariya suffer a lot of mental health problems, which are partially explained by livelihood and poverty-related factors. The loss of homes and displacement compromise mental health, especially the positive emotional well-being related to happiness, life satisfaction, optimism for future, and spiritual contentment. These are often not overcome even with good relocation programs focused on material compensation and livelihood re-establishment.[39] Discussion This systematic review is to our knowledge the first on mental health of ST population in India.

Few studies on the mental health of ST were available. All attempts including hand searching were made to recover both published peer-reviewed papers and reports available on the website. Though we searched gray literature, it may be possible that it does not capture all articles.

Given the heterogeneity of the papers, it was not possible to do a meta-analysis, so a narrative review was done.The quality of the studies was assessed by CASP. The assessment shows that the research conducted on mental health of STs needs to be carried out more effectively. The above mentioned gaps need to be filled in future research by considering the resources effectively while conducting the studies.

Mental and substance use disorders contribute majorly to the health disparities. To address this, one needs to deliver evidence-based treatments, but it is important to understand how far these interventions for the indigenous populations can incorporate cultural practices, which are essential for the development of mental health services.[30] Evidence has shown a disproportionate burden of suicide among indigenous populations in national and regional studies, and a global and systematic investigation of this topic has not been undertaken to date. Previous reviews of suicide epidemiology among indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth, high-income countries, or regions such as Oceania or the Arctic.[46] The only studies in our review which provided data on suicide were in Idu Mishmi, an isolated tribal population of North-East India, and tribal communities from Sunderban delta.[24],[37] Some reasons for suicide in these populations could be the poor identification of existing mental disorders, increased alcohol use, extreme poverty leading to increased debt and hopelessness, and lack of stable employment opportunities.[24],[37] The traditional consumption pattern of alcohol has changed due to the reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement.[19],[20]Faith healers play a dominant role in treating mental disorders.

There is less awareness about mental health and available mental health services and even if such knowledge is available, access is limited due to remoteness of many of these villages, and often it involves high out-of-pocket expenditure.[35] Practitioners of modern medicine can play a vital role in not only increasing awareness about mental health in the community, but also engaging with faith healers and traditional medicine practitioners to help increase their capacity to identify and manage CMDs that do not need medications and can be managed through simple “talk therapy.” Knowledge on symptoms of severe mental disorders can also help such faith healers and traditional medicine practitioners to refer cases to primary care doctors or mental health professionals.Remote settlements make it difficult for ST communities to seek mental health care. Access needs to be increased by using solutions that use training of primary health workers and nonphysician health workers, task sharing, and technology-enabled clinical decision support tools.[3] The SMART Mental Health project was delivered in the tribal areas of Andhra Pradesh using those principles and was found to be beneficial by all stakeholders.[14]Given the lack of knowledge about mental health problems among these communities, the government and nongovernmental organizations should collect and disseminate data on mental disorders among the ST communities. More research funding needs to be provided and key stakeholders should be involved in creating awareness both in the community and among policy makers to develop more projects for ST communities around mental health.

Two recent meetings on tribal mental health – Round Table Meeting on Mental Health of ST Populations organized by the George Institute for Global Health, India, in 2017,[51] and the First National Conference on Tribal Mental Health organized by the Indian Psychiatric Society in Bhubaneswar in 2018 – have identified some key areas of research priority for mental health in ST communities. A national-level policy on mental health of tribal communities or population is advocated which should be developed in consultation with key stakeholders. The Indian Psychiatric Society can play a role in coordinating research activities with support of the government which can ensure regular monitoring and dissemination of the research impact to the tribal communities.

There is a need to understand how mental health symptoms are perceived in different ST communities and investigate the healing practices associated with distress/disaster/death/loss/disease. This could be done in the form of cross-sectional or cohort studies to generate proper evidence which could also include the information on prevalence, mental health morbidity, and any specific patterns associated with a specific disorder. Future research should estimate the prevalence of mental disorders in different age groups and gender, risk factors, and the influence of modernization.

Studies should develop a theoretical model to understand mental disorders and promote positive mental health within ST communities. Studies should also look at different ST communities as cultural differences exist across them, and there are also differences in socioeconomic status which impact on ability to access care.Research has shown that the impact and the benefits are amplified when research is driven by priorities that are identified by indigenous communities and involve their active participation. Their knowledge and perspectives are incorporated in processes and findings.

Reporting of findings is meaningful to the communities. And indigenous groups and other key stakeholders are engaged from the outset.[47] Future research in India on ST communities should also adhere to these broad principles to ensure relevant and beneficial research, which have direct impact on the mental health of the ST communities.There is also a need to update literature related to mental health of ST population continuously. Develop culturally appropriate validated instruments to measure mental morbidity relevant to ST population.

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

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Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].

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