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At the start of 1000mg zithromax online the zithromax, emergency declarations and visit this website insurer policies encouraged the shift to telehealth. Telehealth usage has skyrocketed, often leading patients to grow accustomed to relying on virtual care for its convenience and cost-efficiency.Now, as states across the U.S. Are putting an end to 1000mg zithromax online these policies, telehealth meets one of its biggest hurdles.

Geographic barriers.Dr. Mary Mulcare, chief medical officer at telehealth technology company Summus Global and 1000mg zithromax online an emergency medicine physician at New York-Presbyterian and Weill Cornell Medicine, has been on the front lines of the zithromax. She's seen firsthand how both physicians and patients have adjusted their expectations and processes around virtual care.Healthcare IT News interviewed Mulcare to dig into the reversion to pre-zithromax regulations, the ethics of telemedicine across state lines, what telehealth technologies can do to increase access, and more.Q.

Regarding the future of telehealth after the zithromax, what will be the impact of the reversion to pre-zithromax regulations on both providers and patients 1000mg zithromax online if Congress and the states do not act?. A. There are several ways in which regulatory relaxations have allowed telemedicine 1000mg zithromax online to soar during the zithromax.

HIPAA flexibility, telemedicine waivers through CMS, cost-sharing, and billing and reimbursement changes. While some of these might reasonably be retightened to pre-zithromax levels to improve the delivery of care via this modality, reverting to prior with others would inhibit the progress we have made.Telehealth is a resource that allows patients to access high-quality, experienced physicians across 1000mg zithromax online geographic lines or avoid having to travel for a visit. The breakdown of geographic barriers, and specifically the change allowing providers to practice across state lines, independently from the state(s) in which they are currently licensed, has been an exceedingly valuable step in the right direction.It would be a shame for that to dissolve.

The general practice of medicine 1000mg zithromax online is not defined by state lines. To take this a step further, physicians are different from lawyers, for example. Each state has its own bar and legal text as to which 1000mg zithromax online lawyers need to be adept for that state.

The practice of medicine, on the contrary, is not state-specific but rather can be defined by the experience of providers and resources available.What is at stake if this goes back to the way it was and physicians are bound to treat only patients physically present in the state in which they are licensed?. There will be lost opportunities for patients to achieve the health outcomes they are motivated to or need to obtain.Some patients have specialized needs that historically have required a lot of travel, time and money. The economic impact of health issues for these families and their quality of life has improved while 1000mg zithromax online still allowing them to access their doctors on a regular basis.One of the changes during the zithromax was around the type of communication apps allowed to conduct visits.

The need to utilize a HIPAA-compliant platform became less important than allowing people to access care, which in my opinion was a good trade. Now as we look to telehealth as a permanent part of the spectrum of care, we do need to be careful that 1000mg zithromax online people's private health information is protected and secure.Re-imposing regulatory systems around platforms is valuable for both patients and providers to avoid accidental missteps as we enter a new paradigm with virtual care very much in the mix.Q. How will physicians and patients approach telemedicine care across state lines ethically?.

A. The good news is that the Hippocratic Oath is consistent across the country and across care-delivery modalities. Thus, physicians should be maintaining the same ethical code of conduct regardless of where or how they are seeing patients.If state lines are upheld, we may see increasing situations where patients drive across state lines to have a telemedicine visit from a rest stop.

The value, comfort and convenience of a telemedicine visit is then mostly lost.Doing a physical exam on a patient in a car is more limited. The patient may not have brought their pill bottles with them. They may not have remote monitoring equipment with them to help get a set of vital signs.

All that would have been present potentially in their home. And the point of practicing within a state seems to have been missed.The challenge for providers of working across state lines and into different geographic regions is understanding social stressors and resources present in those areas. For example, asking a patient to go to a local pharmacy across the street in an urban setting is very different from giving someone similar instructions who lives 50 miles driving distance from the nearest pharmacy.As physicians approach treating a patient from regions that are new to them, there also may be different cultural considerations to be taken into account.

Different ethnic groups tend to cluster in different areas of the country, and providers in that space are often very familiar with the preferences of each community.Ultimately, this can be mitigated with education of the telemedicine providers for effective communication techniques and situational awareness. We can also educate patients regarding self-advocacy and raising important concerns with their provider. The balance seems to tip toward community members being provided enhanced access to care rather than waiting or delaying their care due to limited availability.Q.

You've talked about the importance of telehealth for medicine reconciliation and how this critically impacts the geriatric community. Please elaborate.A. One of the powers of telehealth is that it allows providers into the patient's home.

We get a better sense of some of the challenges or supports a patient may have, which is lost in a sterile office setting.This is especially valuable for older adults and those who may have trouble communicating or have cognitive impairment. This is also exceedingly valuable for all patient ages with complicated, chronic medical conditions requiring significant medical and pharmacological support.First, it allows caregivers for the patient to more easily join the conversation when appropriate. Many older adults have multiple caregivers between family and external help, and not all caregivers can be present at an in-person visit.This has been especially true during the zithromax when additional people present in any medical setting has been strongly discouraged.

These caregivers are valuable in providing collateral information and helping us understand what is going on "behind the scenes."Second, there are certain activities, such as medication reconciliation, which should take place during a medical visit that are dramatically facilitated by patients being in their home environment. How many people remember to bring all their pill bottles to an office visit to be able to accurately display what they are taking on a daily basis for medication reconciliation?. Not many.Some may bring their pill boxes where the medication for the week has already been dispensed by a caregiver into individual, day-specific containers.

While possible to do, it takes a lot of time to try and identify each pill individually, comparing each pill to pictures online and available taxonomies of identifiable features, to record what the patient is taking. Physicians are not granted that time in the current model of office visits with our healthcare system.Telehealth allows providers to see the home environment directly. Review each pill bottle and ask the patient whether they are taking it and how often, make sure the patient has enough of the needed medication and then provide timely refills, and have the patient discard expired or no longer needed medications so that there isn't confusion going forward.

Allowing the patient and caregiver to look at the medications in real time while doing this also reinforces any education needed around medication safety and delivery.Speaking of safety, the provider's view into the home also allows for education around fall prevention for older adults and other patients at risk. The provider may see a lack of handrails in key locations or multiple area rugs that are known to cause falls. The provider may also watch the patient use the walker or other home assist devices to give recommendations as to whether they are being used correctly.Q.

When the zithromax is over, what can virtual care platforms do to help increase access and break down geographic barriers to improve patient outcomes?. A. Virtual care companies should strive toward easy-to-use platforms that are HIPAA-compliant and truly facilitate physician-patient interaction.

Outcomes will be reflected in those solutions with high-quality products. People will save time and money while attaining better health when taking part in a seamless connection to the medical world.Patient outcomes will also improve with access to high-quality providers who can relate to specialized needs and are curated to handle a patient's specific concern. People need to be aware of the different options they have available to them in the virtual healthcare world and not be afraid to take advantage of the opportunity.Having a digital gateway to care is exceedingly valuable, yet understandably foreign to many.

We need to raise awareness of the access points now available.With the zithromax, telehealth passed a significant stress test for what it can do and how useful it can be. Physicians have harnessed the technology similarly to patients. Thus, patients shouldn't feel that they will be reaching providers in a less preferred manner.Physicians and other providers have seen the benefit and convenience of practicing medicine when possible in this manner.

Of course there will be times when in-person care is preferable, and we are now becoming able to understand that balance.Twitter. @SiwickiHealthITEmail the writer. Bsiwicki@himss.orgHealthcare IT News is a HIMSS Media publication..

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Maximizing health coverage for read DAP buy zithromax uk clients. Before and after winning the case Outline prepared by Geoffrey Hale and Cathy Roberts - updated August 2012 This outline is intended to assist Disability Advocacy Program (DAP) advocates maximize health insurance coverage for clients they are representing on Social Security/SSI disability determinations. We begin with a discussion of coverage options available while your client’s DAP case is pending and then outline the effect winning the DAP case can have on your client’s access to health care buy zithromax uk coverage.

How your client is affected will vary depending on the source and amount of disability income he or she receives after the successful appeal. I. BACKGROUND buy zithromax uk.

Public health coverage for your clients will primarily be provided by Medicaid and Medicare. The two programs are structured differently and have different eligibility buy zithromax uk criteria, but in order to provide the most complete coverage possible for your clients, they must work effectively together. Understanding their interactions is essential to ensuring benefits for your client.

Here is a brief overview of the programs we will cover. A. Medicaid.

Medicaid is the public insurance program jointly funded by the federal, state and local governments for people of limited means. For federal Medicaid law, see 42 U.S.C. § 1396 et seq., 42 C.F.R.

§ 430 et seq. Regular Medicaid is described in New York’s State Plan and codified at N.Y. Soc.

18 N.Y.C.R.R. § 360, 505. New York also offers several additional programs to provide health care benefits to those whose income might be too high for Regular Medicaid.

i. Family Health Plus (FHPlus) is an extension of New York’s Medicaid program that provides health coverage for adults who are over-income for regular Medicaid. FHPlus is described in New York’s 1115 waiver and codified at N.Y.

§369-ee. ii. Child Health Plus (CHPlus) is a sliding scale premium program for children who are over-income for regular Medicaid.

Medicare is the federal health insurance program providing coverage for the elderly, disabled, and people with end-stage renal disease. Medicare is codified under title XVIII of the Social Security Law, see 42 U.S.C. § 1395 et seq., 42 C.F.R.

§ 400 et seq. Medicare is divided into four parts. i.

Part A covers hospital, skilled nursing facility, home health, and hospice care, with some deductibles and coinsurance. Most people are eligible for Part A at no cost. See 42 U.S.C.

ii. Part B provides medical insurance for doctor’s visits and other outpatient medical services. Medicare Part B has significant cost-sharing components.

There are monthly premiums (the standard premium in 2012 is $99.90. In addition, there is a $135 annual deductible (which will increase to $155 in 2010) as well as 20% co-insurance for most covered out-patient services. See 42 U.S.C.

iii. Part C, also called Medicare Advantage, provides traditional Medicare coverage (Parts A and B) through private managed care insurers. See 42 U.S.C.

Premium amounts for Medicare Advantage plans vary. Some Medicare Advantage plans include prescription drug coverage. iv.

Part D is an optional prescription drug benefit available to anyone with Medicare Parts A and B. See 42 U.S.C. § 1395w, 42 C.F.R.

§ 423.30(a)(1)(i) and (ii). Unlike Parts A and B, Part D benefits are provided directly through private plans offered by insurance companies. In order to receive prescription drug coverage, a Medicare beneficiary must join a Part D Plan or participate in a Medicare Advantage plan that provides prescription drug coverage.

C. Medicare Savings Programs (MSPs). Funded by the State Medicaid program, MSPs help eligible individuals meet some or all of their cost-sharing obligations under Medicare.

L. § 367-a(3)(a), (b), and (d). There are three separate MSPs, each with different eligibility requirements and providing different benefits.

i. Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits.

Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. ii.

Special Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. iii.

Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, but not otherwise Medicaid eligible, the QI-1 program covers Medicare Part B premiums. D.

Medicare Part D Low Income Subsidy (LIS or “Extra Help”). LIS is a federal subsidy administered by CMS that helps Medicare beneficiaries with limited income and/or resources pay for some or most of the costs of Medicare prescription drug coverage. See 42 C.F.R.

§ 423.773. Some of the costs covered in full or in part by LIS include the monthly premiums, annual deductible, co-payments, and the coverage gap. Individuals eligible for Medicaid, SSI, or MSP are deemed eligible for full LIS benefitsSee 42 C.F.R.

§ 423.773(c). LIS applications are treated as (“deemed”) applications for MSP benefits, See the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008, Pub. Law 110-275.

II. WHILE THE DAP APPEAL IS PENDING Does your client have health insurance?. If not, why isn’t s/he getting Medicaid, Family Health Plus or Child Health Plus?.

There have been many recent changes which expand eligibility and streamline the application process. All/most of your DAP clients should qualify. Significant changes to Medicaid include.

Elimination of the resource test for certain categories of Medicaid applicants/recipients and all applicants to the Family Health Plus program. N.Y. Soc.

As of October 1, 2009, a resource test is no longer required for these categories. Elimination of the fingerprinting requirement. N.Y.

§369-ee, as amended by L. 2009, c. 58, pt.

C, § 62. Elimination of the waiting period for CHPlus. N.Y.

2008, c. 58. Elimination of the face-to-face interview requirement for Medicaid, effective April 1, 2010.

58, pt. C, § 60. Higher income levels for Single Adults and Childless Couples.

L. §366(1)(a)(1),(8) as amended by L. 2008, c.

Higher income levels for Medicaid’s Medically Needy program. N.Y. Soc.

GIS 08 MA/022 More detailed information on recent changes to Medicaid is available at. III. AFTER CLIENT IS AWARDED DAP BENEFITS a.

Medicaid eligibility. Clients receiving even $1.00 of SSI should qualify for Medicaid automatically. The process for qualifying will differ, however, depending on the source of payment.

These clients are eligible for full Medicaid without a spend-down. See N.Y. Soc.

ii. Medicaid coverage is automatic. No separate application/ recertification required.

iii. Most SSI-only recipients are required to participate in Medicaid managed care. See N.Y.

Eligible for full Medicaid since receiving SSI. See N.Y. Soc.

They can still qualify for Medicaid but may have a spend-down. Federal Law allows states to use a “spend-down” to extend Medicaid to “medically needy” persons in the federal mandatory categories (children, caretakers, elderly and disabled people) whose income or resources are above the eligibility level for regular Medicaid. See 42 U.S.C.

§ 1396 (a) (10) (ii) (XIII). ii. Under spend-down, applicants in New York’s Medically Needy program can qualify for Medicaid once their income/resources, minus incurred medical expenses, fall below the specified level.

For an explanation of spend-down, see 96 ADM 15. B. Family Health Plus Until your client qualifies for Medicare, those over-income for Medicaid may qualify for Family Health Plus without needing to satisfy a spend-down.

It covers adults without children with income up to 100% of the FPL and adults with children up to 150% of the FPL.[1] The eligibility tests are the same as for regular Medicaid with two additional requirements. Applicants must be between the ages of 19 and 64 and they generally must be uninsured. See N.Y.

§ 369-ee et. Seq. Once your client begins to receive Medicare, he or she will not be eligible for FHP, because FHP is generally only available to those without insurance.

For more information on FHP see our article on Family Health Plus. IV. LOOMING ISSUES - MEDICARE ELIGIBILITY (WHETHER YOU LIKE IT OR NOT) a.

SSI-only cases Clients receiving only SSI aren’t eligible for Medicare until they turn 65, unless they also have End Stage Renal Disease. B. Concurrent (SSD and SSI) cases 1.

Medicare eligibility kicks in beginning with 25th month of SSD receipt. See 42 U.S.C. § 426(f).

Exception. In 2000, Congress eliminated the 24-month waiting period for people diagnosed with ALS (Lou Gehrig’s Disease.) See 42 U.S.C. § 426 (h) 2.

Enrollment in Medicare is a condition of eligibility for Medicaid coverage. These clients cannot decline Medicare coverage. (05 OMM/ADM 5.

Medicaid Reference Guide p. 344.1) 3. Medicare coverage is not free.

Although most individuals receive Part A without any premium, Part B has monthly premiums and significant cost-sharing components. 4. Medicaid and/or the Medicare Savings Program (MSP) should pick up most of Medicare’s cost sharing.

Most SSI beneficiaries are eligible not only for full Medicaid, but also for the most comprehensive MSP, the Qualified Medicare Beneficiary (QMB) program. I. Parts A &.

B (hospital and outpatient/doctors visits). A. Medicaid will pick up premiums, deductibles, co-pays.

L. § 367-a (3) (a). For those not enrolled in an MSP, SSA normally deducts the Part B premium directly from the monthly check.

However, SSI recipients are supposed to be enrolled automatically in QMB, and Medicaid is responsible for covering the premiums. Part B premiums should never be deducted from these clients’ checks.[1] Medicaid and QMB-only recipients should NEVER be billed directly for Part A or B services. Even non-Medicaid providers are supposed to be able to bill Medicaid directly for services.[2] Clients are only responsible for Medicaid co-pay amount.

See 42 U.S.C. § 1396a (n) ii. Part D (prescription drugs).

a. Clients enrolled in Medicaid and/or MSP are deemed eligible for Low Income Subsidy (LIS aka Extra Help). See 42 C.F.R.

§ 423.773(c). SSA POMS SI § 01715.005A.5. New York State If client doesn’t enroll in Part D plan on his/her own, s/he will be automatically assigned to a benchmark[3] plan.

See 42 C.F.R. § 423.34 (d). LIS will pick up most of cost-sharing.[3] Because your clients are eligible for full LIS, they should have NO deductible and NO premium if they are in a benchmark plan, and will not be subject to the coverage gap (aka “donut hole”).

See 42 C.F.R. §§ 423.780 and 423.782. The full LIS beneficiary will also have co-pays limited to either $1.10 or $3.30 (2010 amounts).

See 42 C.F.R. § 423.104 (d) (5) (A). Other important points to remember.

- Medicaid co-pay rules do not apply to Part D drugs. - Your client’s plan may not cover all his/her drugs. - You can help your clients find the plan that best suits their needs.

To figure out what the best Part D plans are best for your particular client, go to www.medicare.gov. Click on “formulary finder” and plug in your client’s medication list. You can enroll in a Part D plan through www.medicare.gov, or by contacting the plan directly.

€“ Your clients can switch plans at any time during the year. Iii. Part C (“Medicare Advantage”).

a. Medicare Advantage plans provide traditional Medicare coverage (Parts A and B) through private managed care insurers. See 42 U.S.C.

Medicare Advantage participation is voluntary. For those clients enrolled in Medicare Advantage Plans, the QMB cost sharing obligations are the same as they are under traditional Medicare. Medicaid must cover any premiums required by the plan, up to the Part B premium amount.

Medicaid must also cover any co-payments and co-insurance under the plan. As with traditional Medicare, both providers and plans are prohibited from billing the beneficiary directly for these co-payments. C.

SSD only individuals. 1. Same Medicare eligibility criteria (24 month waiting period, except for persons w/ ALS).

I. During the 24 month waiting period, explore eligibility for Medicaid or Family Health Plus. 2.

Once Medicare eligibility begins. ii. Parts A &.

B. SSA will automatically enroll your client. Part B premiums will be deducted from monthly Social Security benefits.

(Part A will be free – no monthly premium) Clients have the right to decline ongoing Part B coverage, BUT this is almost never a good idea, and can cause all sorts of headaches if client ever wants to enroll in Part B in the future. (late enrollment penalty and can’t enroll outside of annual enrollment period, unless person is eligible for Medicare Savings Program – see more below) Clients can decline “retro” Part B coverage with no penalty on the Medicare side – just make sure they don’t actually need the coverage. Risky to decline if they had other coverage during the retro period – their other coverage may require that Medicare be utilized if available.

Part A and Part B also have deductibles and co-pays. Medicaid and/or the MSPs can help cover this cost sharing. iii.

Part D. Client must affirmatively enroll in Part D, unless they receive LIS. See 42 U.S.C.

§ 1395w-101 (b) (2), 42 C.F.R. § 423.38 (a). Enrollment is done through individual private plans.

LIS recipients will be auto-assigned to a Part D benchmark plan if they have not selected a plan on their own. Client can decline Part D coverage with no penalty if s/he has “comparable coverage.” 42 C.F.R. § 423.34 (d) (3) (i).

If no comparable coverage, person faces possible late enrollment penalty &. Limited enrollment periods. 42 C.F.R.

§ 423.46. However, clients receiving LIS do not incur any late enrollment penalty. 42 C.F.R.

§ 423.780 (e). Part D has a substantial cost-sharing component – deductibles, premiums and co-pays which vary from plan to plan. There is also the coverage gap, also known as “donut hole,” which can leave beneficiaries picking up 100% of the cost of their drugs until/unless a catastrophic spending limit is reached.

The LIS program can help with Part D cost-sharing. Use Medicare’s website to figure out what plan is best for your client. (Go to www.medicare.gov , click on “formulary finder” and plug in your client’s medication list.

) You can also enroll in a Part D plan directly through www.medicare.gov. Iii. Help with Medicare cost-sharing a.

Medicaid – After eligibility for Medicare starts, client may still be eligible for Medicaid, with or without a spend-down. There are lots of ways to help clients meet their spend-down – including - Medicare cost sharing amounts (deductibles, premiums, co-pays) - over the counter medications if prescribed by a doctor. - expenses paid by state-funded programs like EPIC and ADAP.

- medical bills of person’s spouse or child. - health insurance premiums. - joining a pooled Supplemental Needs Trust (SNT).

B. Medicare Savings Program (MSP) – If client is not eligible for Medicaid, explore eligibility for Medicare Savings Program (MSP). MSP pays for Part B premiums and gets you into the Part D LIS.

There are no asset limits in the Medicare Savings Program. One of the MSPs (QMB), also covers all cost sharing for Parts A &. B.

If your client is eligible for Medicaid AND MSP, enrolling in MSP may subject him/her to, or increase a spend-down, because Medicaid and the various MSPs have different income eligibility levels. It is the client’s choice as to whether or not to be enrolled into MSP. C.

Part D Low Income Subsidy (LIS) – If your client is not eligible for MSP or Medicaid, s/he may still be eligible for Part D Low Income Subsidy. Applications for LIS are also be treated as applications for MSP, unless the client affirmatively indicates that s/he does not want to apply for MSP. d.

Medicare supplemental insurance (Medigap) -- Medigap is supplemental private insurance coverage that covers all or some of the deductibles and coinsurance for Medicare Parts A and B. Medigap is not available to people enrolled in Part C. E.

Medicare Advantage – Medicare Advantage plans “package” Medicare (Part A and B) benefits, with or without Part D coverage, through a private health insurance plan. The cost-sharing structure (deductible, premium, co-pays) varies from plan to plan. For a list of Medicare Advantage plans in your area, go to www.medicare.gov – click on “find health plans.” f.

NY Prescription Saver Card -- NYP$ is a state-sponsored pharmacy discount card that can lower the cost of prescriptions by as much as 60 percent on generics and 30 percent on brand name drugs. Can be used during the Part D “donut hole” (coverage gap) g. For clients living with HIV.

ADAP [AIDS Drug Assistance Program] ADAP provides free medications for the treatment of HIV/AIDS and opportunistic s. ADAP can be used to help meet a Medicaid spenddown and get into the Part D Low Income subsidy. For more information about ADAP, go to V.

GETTING MEDICAID IN THE DISABLED CATEGORY AFTER AN SSI/SSDI DENIAL What if your client's application for SSI or SSDI is denied based on SSA's finding that they were not "disabled?. " Obviously, you have your appeals work cut out for you, but in the meantime, what can they do about health insurance?. It is still possible to have Medicaid make a separate disability determination that is not controlled by the unfavorable SSA determination in certain situations.

Specifically, an applicant is entitled to a new disability determination where he/she. alleges a different or additional disabling condition than that considered by SSA in making its determination. Or alleges less than 12 months after the most recent unfavorable SSA disability determination that his/her condition has changed or deteriorated, alleges a new period of disability which meets the duration requirement, and SSA has refused to reopen or reconsider the allegations, or the individual is now ineligible for SSA benefits for a non-medical reason.

Or alleges more than 12 months after the most recent unfavorable SSA disability determination that his/her condition has changed or deteriorated since the SSA determination and alleges a new period of disability which meets the duration requirement, and has not applied to SSA regarding these allegations. See GIS 10-MA-014 and 08 OHIP/INF-03.[4] [1] Potential wrinkle – for some clients Medicaid is not automatically pick up cost-sharing. In Monroe County we have had several cases where SSA began deducting Medicare Part B premiums from the checks of clients who were receiving SSI and Medicaid and then qualified for Medicare.

The process should be automatic. Please contact Geoffrey Hale in our Rochester office if you encounter any cases like this. [2]Under terms established to provide benefits for QMBs, a provider agreement necessary for reimbursement “may be executed through the submission of a claim to the Medicaid agency requesting Medicaid payment for Medicare deductibles and coinsurance for QMBs.” CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), available at.

http://www.cms.hhs.gov/Manuals/PBM/itemdetail.asp?. ItemID=CMS021927. [3]Benchmark plans are free if you are an LIS recipient.

The amount of the benchmark changes from year to year. In 2013, a Part D plan in New York State is considered benchmark if it provides basic Part D coverage and its monthly premium is $43.22 or less. [4] These citations courtesy of Jim Murphy at Legal Services of Central New York.

This site provides general information only. This is not legal advice. You can only obtain legal advice from a lawyer.

In addition, your use of this site does not create an attorney-client relationship. To contact a lawyer, visit http://lawhelp.org/ny. We make every effort to keep these materials and links up-to-date and in accordance with New York City, New York state and federal law.

However, we do not guarantee the accuracy of this information.Some "dual eligible" beneficiaries (people who have Medicare and Medicaid) are entitled to receive reimbursement of their Medicare Part B premiums from New York State through the Medicare Insurance Premium Payment Program (MIPP). The Part B premium is $148.50 in 2021. MIPP is for some groups who are either not eligible for -- or who are not yet enrolled in-- the Medicare Savings Program (MSP), which is the main program that pays the Medicare Part B premium for low-income people.

Some people are not eligible for an MSP even though they have full Medicaid with no spend down. This is because they are in a special Medicaid eligibility category -- discussed below -- with Medicaid income limits that are actually HIGHER than the MSP income limits. MIPP reimburses them for their Part B premium because they have “full Medicaid” (no spend down) but are ineligible for MSP because their income is above the MSP SLIMB level (120% of the Federal Poverty Level (FPL).

Even if their income is under the QI-1 MSP level (135% FPL), someone cannot have both QI-1 and Medicaid). Instead, these consumers can have their Part B premium reimbursed through the MIPP program. In this article.

The MIPP program was established because the State determined that those who have full Medicaid and Medicare Part B should be reimbursed for their Part B premium, even if they do not qualify for MSP, because Medicare is considered cost effective third party health insurance, and because consumers must enroll in Medicare as a condition of eligibility for Medicaid (See 89 ADM 7). There are generally four groups of dual-eligible consumers that are eligible for MIPP. Therefore, many MBI WPD consumers have incomes higher than what MSP normally allows, but still have full Medicaid with no spend down.

Those consumers can qualify for MIPP and have their Part B premiums reimbursed. Here is an example. Sam is age 50 and has Medicare and MBI-WPD.

She gets $1500/mo gross from Social Security Disability and also makes $400/month through work activity. $ 167.50 -- EARNED INCOME - Because she is disabled, the DAB earned income disregard applies. $400 - $65 = $335.

Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income. This is above the SLIMB limit of $1,288 (2021) but she can still qualify for MIPP. 2.

Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare Beneficiaries. Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time. This is referred to as “MAGI-like budgeting.” Under MAGI rules income can be up to 138% of the FPL—again, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL.

MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income is higher or lower than 120% of the FPL. If their income is under 120% FPL, they are eligible for MSP as a SLIMB. If income is above 120% FPL, then they can enroll in MIPP.

(See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4) When a consumer has Medicaid through the New York State of Health (NYSoH) Marketplace and then enrolls in Medicare when she turns age 65 or because she received Social Security Disability for 24 months, her Medicaid case is normally** transferred to the local department of social services (LDSS)(HRA in NYC) to be rebudgeted under non-MAGI budgeting. During the transition process, she should be reimbursed for the Part B premiums via MIPP. However, the transition time can vary based on age.

AGE 65+ Those who enroll in Medicare at age 65+ will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02. The Medicaid case takes about four months to be rebudgeted and approved by the LDSS.

The consumer is entitled to MIPP payments for at least three months during the transition. Once the case is with the LDSS she should automatically be re-evaluated for MSP, even if the LDSS determines the consumer is not eligible for Medicaid because of excess income or assets. 08 OHIP/ADM-4.

Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY Social Services Law 366, subd. 4(c). These consumers should receive MIPP payments for as long as their cases remain with NYSoH and throughout the transition to the LDSS.

NOTE during buy antibiotics emergency their case may remain with NYSoH for more than 12 months. See here. EXAMPLE.

Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2020. He became enrolled in Medicare based on disability in August 2020, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability). Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2020.

Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund. This will continue until the end of his 12 months of continuous MAGI Medicaid eligibility.

He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district. See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process.

That directive also clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. Note. During the buy antibiotics emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS.

They should keep the same MAGI budgeting and automatically receive MIPP payments. See GIS 20 MA/04 or this article on buy antibiotics eligibility changes 4. Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC).

Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or blind before age 22 to receive the benefit. If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN.

See this article. Consumers may have income higher than MSP limits, but keep full Medicaid with no spend down. Therefore, they are eligible for payment of their Part B premiums.

See page 96 of the Medicaid Reference Guide (Categorical Factors). If their income is lower than the MSP SLIMB threshold, they can be added to MSP. If higher than the threshold, they can be reimbursed via MIPP.

See also 95-ADM-11. Medical Assistance Eligibility for Disabled Adult Children, Section C (pg 8). Pickle &.

1619B. 5. When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit.

The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021). They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium. See GIS 02-MA-019.

Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences. MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check. In contrast, MSP enrollees are not charged for their premium.

Their Social Security check usually increases because the Part B premium is no longer withheld from their check. MIPP only provides reimbursement for Part B. It does not have any of the other benefits MSPs can provide, such as.

A consumer cannot have MIPP without also having Medicaid, whereas MSP enrollees can have MSP only. Of the above benefits, Medicaid also provides Part D Extra Help automatic eligibility. There is no application process for MIPP because consumers should be screened and enrolled automatically (00 OMM/ADM-7).

Either the state or the LDSS is responsible for screening &. Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V). If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment.

Unfortunately, since there is no formal process for applying, it may require some advocacy. If Medicaid case is at New York State of Health they should call 1-855-355-5777. Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP.

If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov. If Medicaid case is with other local districts in NYS, call your local county DSS. See more here about consumers who have Medicaid on NYSofHealth who then enroll in Medicare - how they access MIPP.

Once enrolled, it make take a few months for payments to begin. Payments will be made in the form of checks from the Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid program. The check itself comes attached to a remittance notice from Medicaid Management Information Systems (MMIS).

Unfortunately, the notice is not consumer-friendly and may be confusing. See attached sample for what to look for. Health Insurance Premium Payment Program (HIPP) HIPP is a sister program to MIPP and will reimburse consumers for private third party health insurance when deemed “cost effective.” Directives:.

Maximizing health 1000mg zithromax online coverage for DAP clients https://alistkandb.co.uk/can-you-buy-cialis-over-the-counter-usa. Before and after winning the case Outline prepared by Geoffrey Hale and Cathy Roberts - updated August 2012 This outline is intended to assist Disability Advocacy Program (DAP) advocates maximize health insurance coverage for clients they are representing on Social Security/SSI disability determinations. We begin with a discussion of coverage 1000mg zithromax online options available while your client’s DAP case is pending and then outline the effect winning the DAP case can have on your client’s access to health care coverage. How your client is affected will vary depending on the source and amount of disability income he or she receives after the successful appeal. I.

BACKGROUND 1000mg zithromax online. Public health coverage for your clients will primarily be provided by Medicaid and Medicare. The two programs are structured differently and have different eligibility criteria, but in order to provide the most complete coverage possible for your 1000mg zithromax online clients, they must work effectively together. Understanding their interactions is essential to ensuring benefits for your client. Here is a brief overview of the programs we will cover.

A. Medicaid. Medicaid is the public insurance program jointly funded by the federal, state and local governments for people of limited means. For federal Medicaid law, see 42 U.S.C. § 1396 et seq., 42 C.F.R.

§ 430 et seq. Regular Medicaid is described in New York’s State Plan and codified at N.Y. Soc. Serv. L.

§§ 122, 131, 363- 369-1. 18 N.Y.C.R.R. § 360, 505. New York also offers several additional programs to provide health care benefits to those whose income might be too high for Regular Medicaid. i.

Family Health Plus (FHPlus) is an extension of New York’s Medicaid program that provides health coverage for adults who are over-income for regular Medicaid. FHPlus is described in New York’s 1115 waiver and codified at N.Y. Soc. Serv. L.

§369-ee. ii. Child Health Plus (CHPlus) is a sliding scale premium program for children who are over-income for regular Medicaid. CHPlus is codified at N.Y. Pub.

Health L. §2510 et seq. b. Medicare. Medicare is the federal health insurance program providing coverage for the elderly, disabled, and people with end-stage renal disease.

Medicare is codified under title XVIII of the Social Security Law, see 42 U.S.C. § 1395 et seq., 42 C.F.R. § 400 et seq. Medicare is divided into four parts. i.

Part A covers hospital, skilled nursing facility, home health, and hospice care, with some deductibles and coinsurance. Most people are eligible for Part A at no cost. See 42 U.S.C. § 1395c, 42 C.F.R. Pt.

406. ii. Part B provides medical insurance for doctor’s visits and other outpatient medical services. Medicare Part B has significant cost-sharing components. There are monthly premiums (the standard premium in 2012 is $99.90.

In addition, there is a $135 annual deductible (which will increase to $155 in 2010) as well as 20% co-insurance for most covered out-patient services. See 42 U.S.C. § 1395k, 42 C.F.R. Pt. 407.

iii. Part C, also called Medicare Advantage, provides traditional Medicare coverage (Parts A and B) through private managed care insurers. See 42 U.S.C. § 1395w, 42 C.F.R. Pt.

422. Premium amounts for Medicare Advantage plans vary. Some Medicare Advantage plans include prescription drug coverage. iv. Part D is an optional prescription drug benefit available to anyone with Medicare Parts A and B.

See 42 U.S.C. § 1395w, 42 C.F.R. § 423.30(a)(1)(i) and (ii). Unlike Parts A and B, Part D benefits are provided directly through private plans offered by insurance companies. In order to receive prescription drug coverage, a Medicare beneficiary must join a Part D Plan or participate in a Medicare Advantage plan that provides prescription drug coverage.

C. Medicare Savings Programs (MSPs). Funded by the State Medicaid program, MSPs help eligible individuals meet some or all of their cost-sharing obligations under Medicare. See N.Y. Soc.

Serv. L. § 367-a(3)(a), (b), and (d). There are three separate MSPs, each with different eligibility requirements and providing different benefits. i.

Qualified Medicare Beneficiary (QMB). The QMB program provides the most comprehensive benefits. Available to those with incomes at or below 100% of the Federal Poverty Level (FPL), the QMB program covers virtually all Medicare cost-sharing obligations. Part B premiums, Part A premiums, if there are any, and any and all deductibles and co-insurance. ii.

Special Low-Income Medicare Beneficiary (SLMB). For those with incomes between 100% and 120% FPL, the SLMB program will cover Part B premiums only. iii. Qualified Individual (QI-1). For those with incomes between 120% and 135% FPL, but not otherwise Medicaid eligible, the QI-1 program covers Medicare Part B premiums.

D. Medicare Part D Low Income Subsidy (LIS or “Extra Help”). LIS is a federal subsidy administered by CMS that helps Medicare beneficiaries with limited income and/or resources pay for some or most of the costs of Medicare prescription drug coverage. See 42 C.F.R. § 423.773.

Some of the costs covered in full or in part by LIS include the monthly premiums, annual deductible, co-payments, and the coverage gap. Individuals eligible for Medicaid, SSI, or MSP are deemed eligible for full LIS benefitsSee 42 C.F.R. § 423.773(c). LIS applications are treated as (“deemed”) applications for MSP benefits, See the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008, Pub. Law 110-275.

II. WHILE THE DAP APPEAL IS PENDING Does your client have health insurance?. If not, why isn’t s/he getting Medicaid, Family Health Plus or Child Health Plus?. There have been many recent changes which expand eligibility and streamline the application process. All/most of your DAP clients should qualify.

Significant changes to Medicaid include. Elimination of the resource test for certain categories of Medicaid applicants/recipients and all applicants to the Family Health Plus program. N.Y. Soc. Serv.

L. §369-ee (2), as amended by L. 2009, c. 58, pt. C, § 59-d.

As of October 1, 2009, a resource test is no longer required for these categories. Elimination of the fingerprinting requirement. N.Y. Soc. Serv.

L. §369-ee, as amended by L. 2009, c. 58, pt. C, § 62.

Elimination of the waiting period for CHPlus. N.Y. Pub. Health L. §2511, as amended by L.

2008, c. 58. Elimination of the face-to-face interview requirement for Medicaid, effective April 1, 2010. N.Y. Soc.

Serv. L. §366-a (1), as amended by L. 2009, c. 58, pt.

C, § 60. Higher income levels for Single Adults and Childless Couples. N.Y. Soc. Serv.

L. §366(1)(a)(1),(8) as amended by L. 2008, c. 58. See also.

GIS 08 MA/022. Higher income levels for Medicaid’s Medically Needy program. N.Y. Soc. Serv.

L. §366(2)(a)(7) as amended by L. 2008, c. 58. See also.

GIS 08 MA/022 More detailed information on recent changes to Medicaid is available at. III. AFTER CLIENT IS AWARDED DAP BENEFITS a. Medicaid eligibility. Clients receiving even $1.00 of SSI should qualify for Medicaid automatically.

The process for qualifying will differ, however, depending on the source of payment. 1. Clients Receiving SSI Only. i. These clients are eligible for full Medicaid without a spend-down.

ii. Medicaid coverage is automatic. No separate application/ recertification required. iii. Most SSI-only recipients are required to participate in Medicaid managed care.

2. Concurrent (SSI/SSD) cases. Eligible for full Medicaid since receiving SSI. See N.Y. Soc.

I. They can still qualify for Medicaid but may have a spend-down. Federal Law allows states to use a “spend-down” to extend Medicaid to “medically needy” persons in the federal mandatory categories (children, caretakers, elderly and disabled people) whose income or resources are above the eligibility level for regular Medicaid. See 42 U.S.C. § 1396 (a) (10) (ii) (XIII).

ii. Under spend-down, applicants in New York’s Medically Needy program can qualify for Medicaid once their income/resources, minus incurred medical expenses, fall below the specified level. For an explanation of spend-down, see 96 ADM 15. B. Family Health Plus Until your client qualifies for Medicare, those over-income for Medicaid may qualify for Family Health Plus without needing to satisfy a spend-down.

It covers adults without children with income up to 100% of the FPL and adults with children up to 150% of the FPL.[1] The eligibility tests are the same as for regular Medicaid with two additional requirements. Applicants must be between the ages of 19 and 64 and they generally must be uninsured. See N.Y. Soc. Serv.

L. § 369-ee et. Seq. Once your client begins to receive Medicare, he or she will not be eligible for FHP, because FHP is generally only available to those without insurance. For more information on FHP see our article on Family Health Plus.

IV. LOOMING ISSUES - MEDICARE ELIGIBILITY (WHETHER YOU LIKE IT OR NOT) a. SSI-only cases Clients receiving only SSI aren’t eligible for Medicare until they turn 65, unless they also have End Stage Renal Disease. B. Concurrent (SSD and SSI) cases 1.

Medicare eligibility kicks in beginning with 25th month of SSD receipt. See 42 U.S.C. § 426(f). Exception. In 2000, Congress eliminated the 24-month waiting period for people diagnosed with ALS (Lou Gehrig’s Disease.) See 42 U.S.C.

§ 426 (h) 2. Enrollment in Medicare is a condition of eligibility for Medicaid coverage. These clients cannot decline Medicare coverage. (05 OMM/ADM 5. Medicaid Reference Guide p.

344.1) 3. Medicare coverage is not free. Although most individuals receive Part A without any premium, Part B has monthly premiums and significant cost-sharing components. 4. Medicaid and/or the Medicare Savings Program (MSP) should pick up most of Medicare’s cost sharing.

Most SSI beneficiaries are eligible not only for full Medicaid, but also for the most comprehensive MSP, the Qualified Medicare Beneficiary (QMB) program. I. Parts A &. B (hospital and outpatient/doctors visits). A.

Medicaid will pick up premiums, deductibles, co-pays. N.Y. Soc. Serv. L.

§ 367-a (3) (a). For those not enrolled in an MSP, SSA normally deducts the Part B premium directly from the monthly check. However, SSI recipients are supposed to be enrolled automatically in QMB, and Medicaid is responsible for covering the premiums. Part B premiums should never be deducted from these clients’ checks.[1] Medicaid and QMB-only recipients should NEVER be billed directly for Part A or B services. Even non-Medicaid providers are supposed to be able to bill Medicaid directly for services.[2] Clients are only responsible for Medicaid co-pay amount.

See 42 U.S.C. § 1396a (n) ii. Part D (prescription drugs). a. Clients enrolled in Medicaid and/or MSP are deemed eligible for Low Income Subsidy (LIS aka Extra Help).

See 42 C.F.R. § 423.773(c). SSA POMS SI § 01715.005A.5. New York State If client doesn’t enroll in Part D plan on his/her own, s/he will be automatically assigned to a benchmark[3] plan. See 42 C.F.R.

§ 423.34 (d). LIS will pick up most of cost-sharing.[3] Because your clients are eligible for full LIS, they should have NO deductible and NO premium if they are in a benchmark plan, and will not be subject to the coverage gap (aka “donut hole”). See 42 C.F.R. §§ 423.780 and 423.782. The full LIS beneficiary will also have co-pays limited to either $1.10 or $3.30 (2010 amounts).

See 42 C.F.R. § 423.104 (d) (5) (A). Other important points to remember. - Medicaid co-pay rules do not apply to Part D drugs. - Your client’s plan may not cover all his/her drugs.

- You can help your clients find the plan that best suits their needs. To figure out what the best Part D plans are best for your particular client, go to www.medicare.gov. Click on “formulary finder” and plug in your client’s medication list. You can enroll in a Part D plan through www.medicare.gov, or by contacting the plan directly. €“ Your clients can switch plans at any time during the year.

Iii. Part C (“Medicare Advantage”). a. Medicare Advantage plans provide traditional Medicare coverage (Parts A and B) through private managed care insurers. See 42 U.S.C.

§ 1395w, 42 C.F.R. Pt. 422. Medicare Advantage participation is voluntary. For those clients enrolled in Medicare Advantage Plans, the QMB cost sharing obligations are the same as they are under traditional Medicare.

Medicaid must cover any premiums required by the plan, up to the Part B premium amount. Medicaid must also cover any co-payments and co-insurance under the plan. As with traditional Medicare, both providers and plans are prohibited from billing the beneficiary directly for these co-payments. C. SSD only individuals.

1. Same Medicare eligibility criteria (24 month waiting period, except for persons w/ ALS). I. During the 24 month waiting period, explore eligibility for Medicaid or Family Health Plus. 2.

Once Medicare eligibility begins. ii. Parts A &. B. SSA will automatically enroll your client.

Part B premiums will be deducted from monthly Social Security benefits. (Part A will be free – no monthly premium) Clients have the right to decline ongoing Part B coverage, BUT this is almost never a good idea, and can cause all sorts of headaches if client ever wants to enroll in Part B in the future. (late enrollment penalty and can’t enroll outside of annual enrollment period, unless person is eligible for Medicare Savings Program – see more below) Clients can decline “retro” Part B coverage with no penalty on the Medicare side – just make sure they don’t actually need the coverage. Risky to decline if they had other coverage during the retro period – their other coverage may require that Medicare be utilized if available. Part A and Part B also have deductibles and co-pays.

Medicaid and/or the MSPs can help cover this cost sharing. iii. Part D. Client must affirmatively enroll in Part D, unless they receive LIS. See 42 U.S.C.

§ 1395w-101 (b) (2), 42 C.F.R. § 423.38 (a). Enrollment is done through individual private plans. LIS recipients will be auto-assigned to a Part D benchmark plan if they have not selected a plan on their own. Client can decline Part D coverage with no penalty if s/he has “comparable coverage.” 42 C.F.R.

§ 423.34 (d) (3) (i). If no comparable coverage, person faces possible late enrollment penalty &. Limited enrollment periods. 42 C.F.R. § 423.46.

However, clients receiving LIS do not incur any late enrollment penalty. 42 C.F.R. § 423.780 (e). Part D has a substantial cost-sharing component – deductibles, premiums and co-pays which vary from plan to plan. There is also the coverage gap, also known as “donut hole,” which can leave beneficiaries picking up 100% of the cost of their drugs until/unless a catastrophic spending limit is reached.

The LIS program can help with Part D cost-sharing. Use Medicare’s website to figure out what plan is best for your client. (Go to www.medicare.gov , click on “formulary finder” and plug in your client’s medication list. ) You can also enroll in a Part D plan directly through www.medicare.gov. Iii.

Help with Medicare cost-sharing a. Medicaid – After eligibility for Medicare starts, client may still be eligible for Medicaid, with or without a spend-down. There are lots of ways to help clients meet their spend-down – including - Medicare cost sharing amounts (deductibles, premiums, co-pays) - over the counter medications if prescribed by a doctor. - expenses paid by state-funded programs like EPIC and ADAP. - medical bills of person’s spouse or child.

- health insurance premiums. - joining a pooled Supplemental Needs Trust (SNT). B. Medicare Savings Program (MSP) – If client is not eligible for Medicaid, explore eligibility for Medicare Savings Program (MSP). MSP pays for Part B premiums and gets you into the Part D LIS.

There are no asset limits in the Medicare Savings Program. One of the MSPs (QMB), also covers all cost sharing for Parts A &. B. If your client is eligible for Medicaid AND MSP, enrolling in MSP may subject him/her to, or increase a spend-down, because Medicaid and the various MSPs have different income eligibility levels. It is the client’s choice as to whether or not to be enrolled into MSP.

C. Part D Low Income Subsidy (LIS) – If your client is not eligible for MSP or Medicaid, s/he may still be eligible for Part D Low Income Subsidy. Applications for LIS are also be treated as applications for MSP, unless the client affirmatively indicates that s/he does not want to apply for MSP. d. Medicare supplemental insurance (Medigap) -- Medigap is supplemental private insurance coverage that covers all or some of the deductibles and coinsurance for Medicare Parts A and B.

Medigap is not available to people enrolled in Part C. E. Medicare Advantage – Medicare Advantage plans “package” Medicare (Part A and B) benefits, with or without Part D coverage, through a private health insurance plan. The cost-sharing structure (deductible, premium, co-pays) varies from plan to plan. For a list of Medicare Advantage plans in your area, go to www.medicare.gov – click on “find health plans.” f.

NY Prescription Saver Card -- NYP$ is a state-sponsored pharmacy discount card that can lower the cost of prescriptions by as much as 60 percent on generics and 30 percent on brand name drugs. Can be used during the Part D “donut hole” (coverage gap) g. For clients living with HIV. ADAP [AIDS Drug Assistance Program] ADAP provides free medications for the treatment of HIV/AIDS and opportunistic s. ADAP can be used to help meet a Medicaid spenddown and get into the Part D Low Income subsidy.

For more information about ADAP, go to V. GETTING MEDICAID IN THE DISABLED CATEGORY AFTER AN SSI/SSDI DENIAL What if your client's application for SSI or SSDI is denied based on SSA's finding that they were not "disabled?. " Obviously, you have your appeals work cut out for you, but in the meantime, what can they do about health insurance?. It is still possible to have Medicaid make a separate disability determination that is not controlled by the unfavorable SSA determination in certain situations. Specifically, an applicant is entitled to a new disability determination where he/she.

alleges a different or additional disabling condition than that considered by SSA in making its determination. Or alleges less than 12 months after the most recent unfavorable SSA disability determination that his/her condition has changed or deteriorated, alleges a new period of disability which meets the duration requirement, and SSA has refused to reopen or reconsider the allegations, or the individual is now ineligible for SSA benefits for a non-medical reason. Or alleges more than 12 months after the most recent unfavorable SSA disability determination that his/her condition has changed or deteriorated since the SSA determination and alleges a new period of disability which meets the duration requirement, and has not applied to SSA regarding these allegations. See GIS 10-MA-014 and 08 OHIP/INF-03.[4] [1] Potential wrinkle – for some clients Medicaid is not automatically pick up cost-sharing. In Monroe County we have had several cases where SSA began deducting Medicare Part B premiums from the checks of clients who were receiving SSI and Medicaid and then qualified for Medicare.

The process should be automatic. Please contact Geoffrey Hale in our Rochester office if you encounter any cases like this. [2]Under terms established to provide benefits for QMBs, a provider agreement necessary for reimbursement “may be executed through the submission of a claim to the Medicaid agency requesting Medicaid payment for Medicare deductibles and coinsurance for QMBs.” CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), available at. http://www.cms.hhs.gov/Manuals/PBM/itemdetail.asp?. ItemID=CMS021927.

[3]Benchmark plans are free if you are an LIS recipient. The amount of the benchmark changes from year to year. In 2013, a Part D plan in New York State is considered benchmark if it provides basic Part D coverage and its monthly premium is $43.22 or less. [4] These citations courtesy of Jim Murphy at Legal Services of Central New York. This site provides general information only.

This is not legal advice. You can only obtain legal advice from a lawyer. In addition, your use of this site does not create an attorney-client relationship. To contact a lawyer, visit http://lawhelp.org/ny. We make every effort to keep these materials and links up-to-date and in accordance with New York City, New York state and federal law.

However, we do not guarantee the accuracy of this information.Some "dual eligible" beneficiaries (people who have Medicare and Medicaid) are entitled to receive reimbursement of their Medicare Part B premiums from New York State through the Medicare Insurance Premium Payment Program (MIPP). The Part B premium is $148.50 in 2021. MIPP is for some groups who are either not eligible for -- or who are not yet enrolled in-- the Medicare Savings Program (MSP), which is the main program that pays the Medicare Part B premium for low-income people. Some people are not eligible for an MSP even though they have full Medicaid with no spend down. This is because they are in a special Medicaid eligibility category -- discussed below -- with Medicaid income limits that are actually HIGHER than the MSP income limits.

MIPP reimburses them for their Part B premium because they have “full Medicaid” (no spend down) but are ineligible for MSP because their income is above the MSP SLIMB level (120% of the Federal Poverty Level (FPL). Even if their income is under the QI-1 MSP level (135% FPL), someone cannot have both QI-1 and Medicaid). Instead, these consumers can have their Part B premium reimbursed through the MIPP program. In this article. The MIPP program was established because the State determined that those who have full Medicaid and Medicare Part B should be reimbursed for their Part B premium, even if they do not qualify for MSP, because Medicare is considered cost effective third party health insurance, and because consumers must enroll in Medicare as a condition of eligibility for Medicaid (See 89 ADM 7).

There are generally four groups of dual-eligible consumers that are eligible for MIPP. Therefore, many MBI WPD consumers have incomes higher than what MSP normally allows, but still have full Medicaid with no spend down. Those consumers can qualify for MIPP and have their Part B premiums reimbursed. Here is an example. Sam is age 50 and has Medicare and MBI-WPD.

She gets $1500/mo gross from Social Security Disability and also makes $400/month through work activity. $ 167.50 -- EARNED INCOME - Because she is disabled, the DAB earned income disregard applies. $400 - $65 = $335. Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income. This is above the SLIMB limit of $1,288 (2021) but she can still qualify for MIPP.

2. Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare Beneficiaries. Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time. This is referred to as “MAGI-like budgeting.” Under MAGI rules income can be up to 138% of the FPL—again, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL. MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income is higher or lower than 120% of the FPL.

If their income is under 120% FPL, they are eligible for MSP as a SLIMB. If income is above 120% FPL, then they can enroll in MIPP. (See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4) When a consumer has Medicaid through the New York State of Health (NYSoH) Marketplace and then enrolls in Medicare when she turns age 65 or because she received Social Security Disability for 24 months, her Medicaid case is normally** transferred to the local department of social services (LDSS)(HRA in NYC) to be rebudgeted under non-MAGI budgeting. During the transition process, she should be reimbursed for the Part B premiums via MIPP. However, the transition time can vary based on age.

AGE 65+ Those who enroll in Medicare at age 65+ will receive a letter from their local district asking them to "renew" Medicaid through their local district. See 2014 LCM-02. The Medicaid case takes about four months to be rebudgeted and approved by the LDSS. The consumer is entitled to MIPP payments for at least three months during the transition. Once the case is with the LDSS she should automatically be re-evaluated for MSP, even if the LDSS determines the consumer is not eligible for Medicaid because of excess income or assets.

08 OHIP/ADM-4. Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY Social Services Law 366, subd. 4(c). These consumers should receive MIPP payments for as long as their cases remain with NYSoH and throughout the transition to the LDSS. NOTE during buy antibiotics emergency their case may remain with NYSoH for more than 12 months.

See here. EXAMPLE. Sam, age 60, was last authorized for Medicaid on the Marketplace in June 2020. He became enrolled in Medicare based on disability in August 2020, and started receiving Social Security in the same month (he won a hearing approving Social Security disability benefits retroactively, after first being denied disability). Even though his Social Security is too high, he can keep Medicaid for 12 months beginning June 2020.

Sam has to pay for his Part B premium - it is deducted from his Social Security check. He may call the Marketplace and request a refund. This will continue until the end of his 12 months of continuous MAGI Medicaid eligibility. He will be reimbursed regardless of whether he is in a Medicaid managed care plan. See GIS 18 MA/001 Medicaid Managed Care Transition for Enrollees Gaining Medicare (PDF) When that ends, he will renew Medicaid and apply for MSP with his local district.

See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process. That directive also clarified that reimbursement of the Part B premium will be made regardless of whether the individual is still in a Medicaid managed care (MMC) plan. Note. During the buy antibiotics emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS. They should keep the same MAGI budgeting and automatically receive MIPP payments.

See GIS 20 MA/04 or this article on buy antibiotics eligibility changes 4. Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC). Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or blind before age 22 to receive the benefit. If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN.

See this article. Consumers may have income higher than MSP limits, but keep full Medicaid with no spend down. Therefore, they are eligible for payment of their Part B premiums. See page 96 of the Medicaid Reference Guide (Categorical Factors). If their income is lower than the MSP SLIMB threshold, they can be added to MSP.

If higher than the threshold, they can be reimbursed via MIPP. See also 95-ADM-11. Medical Assistance Eligibility for Disabled Adult Children, Section C (pg 8). Pickle &. 1619B.

5. When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit. The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021). They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium. See GIS 02-MA-019.

Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences. MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check. In contrast, MSP enrollees are not charged for their premium. Their Social Security check usually increases because the Part B premium is no longer withheld from their check. MIPP only provides reimbursement for Part B.

It does not have any of the other benefits MSPs can provide, such as. A consumer cannot have MIPP without also having Medicaid, whereas MSP enrollees can have MSP only. Of the above benefits, Medicaid also provides Part D Extra Help automatic eligibility. There is no application process for MIPP because consumers should be screened and enrolled automatically (00 OMM/ADM-7). Either the state or the LDSS is responsible for screening &.

Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V). If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment. Unfortunately, since there is no formal process for applying, it may require some advocacy. If Medicaid case is at New York State of Health they should call 1-855-355-5777. Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP.

If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov. If Medicaid case is with other local districts in NYS, call your local county DSS. See more here about consumers who have Medicaid on NYSofHealth who then enroll in Medicare - how they access MIPP. Once enrolled, it make take a few months for payments to begin. Payments will be made in the form of checks from the Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid program.

The check itself comes attached to a remittance notice from Medicaid Management Information Systems (MMIS). Unfortunately, the notice is not consumer-friendly and may be confusing. See attached sample for what to look for. Health Insurance Premium Payment Program (HIPP) HIPP is a sister program to MIPP and will reimburse consumers for private third party health insurance when deemed “cost effective.” Directives:.

What should I watch for while taking Zithromax?

Tell your prescriber or health care professional if your symptoms do not improve in 2 to 3 days. Contact your prescriber or health care professional as soon as you can if you get an allergic reaction to azithromycin, such as rash, itching, difficulty swallowing, or swelling of the face, lips or tongue. Keep out of the sun, or wear protective clothing outdoors and use a sunscreen. Do not use sun lamps or sun tanning beds or booths. If you get severe or watery diarrhea, do not treat yourself. Call your prescriber or health care professional for advice. Antacids can stop azithromycin from working. If you get an upset stomach and want to take an antacid, make sure there is an interval of at least 2 hours since you last took azithromycin, or 4 hours before your next dose. If you are going to have surgery, tell your prescriber or health care professional that you are taking azithromycin.

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A year http://upheavalworld.com/how-much-does-propecia-cost-per-pill/ ago, in August 2020 Rescue, azithromycin zithromax dosage for chlamydia Calif. Resident Sharon azithromycin zithromax dosage for chlamydia Benton received the phone call that every mother dreads. Kyle Benton was hospitalized for 43 days.Her 18-year-old son Kyle was longboarding with a friend.

He was going downhill fast, when he went flying off of his azithromycin zithromax dosage for chlamydia board. The back of his skull hit the pavement and he sustained a fracture, six inches wide. He wasn’t wearing a helmet azithromycin zithromax dosage for chlamydia.

His friend called 911 immediately. Paramedics from the El Dorado Hills Fire Department arrived and he was rushed by ambulance to the UC Davis Pediatric Intensive Care Unit azithromycin zithromax dosage for chlamydia (PICU).The National Safety Council reports that 217,646 people in the United States were treated in hospital emergency rooms for longboarding, skateboarding and hoverboarding injuries in 2020. The majority (more than 81,000) of those injuries occurred in children ages 5 to azithromycin zithromax dosage for chlamydia 14.‘It broke my heart to see him like that’As a result of his fall, Kyle suffered a traumatic brain injury (TBI), a skull fracture, a subdural hematoma (a buildup of blood on the surface of the brain) and a blood clot in the brain.“You have to believe in miracles.

That’s what Kyle is to us. A walking azithromycin zithromax dosage for chlamydia miracle.”— Sharon BentonAs hours passed, more injuries were added to the growing list. He had suffered broken vertebrae.

He also had pneumonia, a common complication of severe brain injury.“When I walked azithromycin zithromax dosage for chlamydia into the doors of this hospital, I had no idea what to expect or when we would be able to bring Kyle home. And, to be honest, if we would be able to bring Kyle home again,” said Sharon Benton.Her first sight of her son in the hospital. Kyle lying still, surrounded by endless cords azithromycin zithromax dosage for chlamydia attached to monitors.

A brace propped his neck into place. A ventilator was azithromycin zithromax dosage for chlamydia breathing for him. He was in a medically azithromycin zithromax dosage for chlamydia induced coma.“It broke my heart to see him like that,” Benton said.

€œBut the doctors and nurses were so gifted, compassionate and kind. Our nurses were there for me, cried with me and got me through those difficult days.”Kyle had physical, occupational and speech therapy six days a week while hospitalized.Kyle azithromycin zithromax dosage for chlamydia would remain in that state for two weeks. During this time, UC Davis neurosurgeon Orin Bloch successfully performed a decompressive craniectomy, a surgery to remove a portion of his skull to relieve the swelling in his brain.

Months later, he would have a cranial reconstruction to re-form the part of his skull that was removed.Then, azithromycin zithromax dosage for chlamydia slowly, his medical team weaned him from the sedatives and pain medicine. It was a daily balancing act to keep him stable and comfortable but progressing forward.9 safety tips for longboardersLongboarding is a style of skateboarding, using longboards which usually are 42 to 80 inches long compared to 30- to 38-inch-long skateboards. Longboards are flat and build speed when going downhill.The American Academy of Pediatrics advises azithromycin zithromax dosage for chlamydia riders of skateboards and longboards to follow these safety precautions:• Wear a helmet that meets safety standards.

Look for a label on the helmet azithromycin zithromax dosage for chlamydia that reads ASTM F1492 or Snell N-94. This means the helmet is specially designed to protect skateboarders, longboarders and roller/inline skaters.• Wear protective gear. Wrist guards, knee and elbow pads, and shoes with flat soles.• Make sure the wheels and hardware are secure before riding.• Be aware of speed wobble, when the board moves from side to side unexpectedly azithromycin zithromax dosage for chlamydia and causes the rider to fall off.

To prevent it, ride forward on the board and crouch. Longer boards with wheels that are farther apart may be less likely to have speed wobble.• Check local laws before riding azithromycin zithromax dosage for chlamydia in public. Some cities have rules about where longboards and skateboards can be ridden.

Never ride alone or in low light.• Watch out for holes, rocks and bumpy riding surfaces.• Never ride under azithromycin zithromax dosage for chlamydia the influence of alcohol or drugs.• Use community skateboard parks instead of riding on homemade ramps or jumps. The parks are away from motor vehicle traffic, and ramps are monitored for safety.• Children under age 5 should not ride the boards, and children ages 5-10 should be supervised.Sharon started an online Facebook group, Prayers for Kyle Benton, to update her family and friends regularly about Kyle’s progress. Soon, she had a global following of azithromycin zithromax dosage for chlamydia thousands of people she had never met, who were keeping Kyle and her family in their prayers.

She will forever remember Sept azithromycin zithromax dosage for chlamydia. 11, 2020 as the turning point in Kyle’s patient journey. She posted to her azithromycin zithromax dosage for chlamydia Facebook group, “We have seen many changes in Kyle over the last 18 hours.

His eyes started fluttering. His arms azithromycin zithromax dosage for chlamydia and legs are moving. They are lowering all meds and respiratory aids.

This may take a couple of days, but Kyle is waking up.”On azithromycin zithromax dosage for chlamydia the road to recoveryWhen Kyle came out of his coma, physical, speech and occupational therapy began in the hospital, six days a week.“When our rehab team first met Kyle, he was non-verbal, not comprehending much and was fed by a tube,” said speech therapist Michelle Ramirez. €œKyle progressed quickly and was very determined and motivated. He was azithromycin zithromax dosage for chlamydia such a pleasure to have in therapy, always willing to do the hard and boring tasks he knew would make him stronger.” Music therapy also helped provided much-needed healing for Kyle.

An avid musician who plays both piano and guitar, Kyle azithromycin zithromax dosage for chlamydia was able to receive daily visits from music therapist Tori Steeley. He would play songs with her that he enjoyed.“The first time I met Kyle, his mom showed me videos of him playing music with his friends. Kyle expressed concern several times during that visit that he didn’t remember how to play azithromycin zithromax dosage for chlamydia music,” Steeley said.

€œMusic therapy was used to find the ways that Kyle could still positively and easily engage in music-making. We realized azithromycin zithromax dosage for chlamydia that although reading or recalling specific musical pieces was frustrating for him, he easily remembered guitar and piano chords. Music therapy sessions were often spent with Kyle playing Elton John or Beatles songs on guitar and piano, focusing on Kyle’s strengths as a musician.”A walking miracleOn the one-year anniversary of his injury, Kyle Benton celebrated at Disneyland with his family.On Oct.

13, the Benton azithromycin zithromax dosage for chlamydia family got the miracle they were hoping for. After 43 days of hospitalization, azithromycin zithromax dosage for chlamydia Kyle was discharged from the hospital and was able to walk out on his own. €œKyle’s recovery is a testament to his determination, his parents’ support and advocacy and his medical team walking alongside him, pushing him each step.

We are grateful to be able azithromycin zithromax dosage for chlamydia to see him make his way now to college,” Ramirez said. Kyle recently celebrated his 19th birthday. This week, he will be leaving home for Brigham Young University Idaho, where he will azithromycin zithromax dosage for chlamydia begin his freshman year.

These are milestones that the Benton family had dreamed of during Kyle’s long battle and recovery.“We are extremely thankful to everyone who was there to take care of Kyle. From our good friend Stacy Minnich who was one of his first azithromycin zithromax dosage for chlamydia responders, to the medical staff at UC Davis. Together, these people and God saved his life,” Benton said.

€œYou have azithromycin zithromax dosage for chlamydia to believe in miracles. That’s what Kyle azithromycin zithromax dosage for chlamydia is to us. A walking miracle.”The UC Davis School of Medicine will develop a new academic pathway to train students interested in caring for the Native American and Alaskan Native communities, thanks to a boost in state funding.

UC Davis is committed to increasing azithromycin zithromax dosage for chlamydia the number of Native American medical students like Eleanor Adams who came here from the RISE pathway.The $1.7 million allocation, included in the state budget signed by Gov. Gavin Newsom in July, comes after years of advocacy by the University of California (UC), which has sought to secure money for ongoing and new medical education programs across several campuses.The programs are part of a UC-wide initiative known as PRIME (Programs in Medical Education), which intend to fill the shortage of doctors in medically underserved areas and reduce health disparities. In addition to the funding to create the new Native American PRIME, UC azithromycin zithromax dosage for chlamydia Davis will receive another $1.7 million to bolster its Rural PRIME pathway, which trains students to address health issues in rural communities.“This is a huge, huge win for us,” said Mark Servis, UC Davis professor of clinical psychiatry and vice dean for medical education at the School of Medicine.

€œIt’s an incredible development because we’ve been working on addressing the needs of tribal communities for years, and this positions us as a national leader. We also have to subsidize our PRIME programs, and this adds the financial resources needed to support these programs.”Reducing health disparities through PRIMEIn all, the state budget is providing nearly $13 million to enable seven UC schools to boost enrollment and start new programs.In addition to UC Davis, the funding azithromycin zithromax dosage for chlamydia will benefit UC San Diego, UC Riverside, UC Irvine, UCLA, UCSF and UC Berkeley. PRIME was conceived by the UC Office of the President in 2004 to allow medical schools to offer education pathways that include rotations in hospitals and clinics unique to a geographic area or primary care setting.School of Medicine leaders said the new PRIME pathway will be a draw for Native American students who are eager to become doctors and improve the health of Native Americans in California.“The ultimate dream is to have a positive impact in the health of underserved communities in California by recruiting students who are passionate about their communities and giving them the tools and training to go back and serve those same communities.”— Alicia González-Floresexecutive directorUC Davis School of Medicine’s Community Health ScholarsStudies show that students and residents who are passionate about delivering care in medically underserved areas will likely end up working there as physicians.AIAN populations have long experienced more health complications than other groups, including higher death rates from chronic liver disease and cirrhosis, unintentional injuries and chronic lower respiratory diseases, according to Indian Health Services, a federal initiative.Very few AIAN students apply to medical schools in California, and UC Davis wants to help change that.“The mission of our medical education is to address the physician shortage in areas that really need it, and we know that for tribal communities that need is enormous,” said Alicia González-Flores, a UC Davis Health associate professor in internal medicine and executive director of Community Health Scholars, which administers PRIME.UC Davis was selected for the new track in partnership with UC San Diego, which has the largest cohort of Native American students among UC medical schools.Latest in ongoing effort to boost number of Native American doctorsThe UC Davis School of Medicine has made it a priority to recruit Native American students, and students committed to serving AIAN communities in our region, said pediatrician Eric Crossen, a health sciences clinical associate professor and director of the UC Davis Tribal Health Programs.The effort the past several years includes a multi-sector partnership called RISE, or Reimagine Indians into Medicine.

It involves azithromycin zithromax dosage for chlamydia two other universities, Oregon Health &. Science University (OHSU) and azithromycin zithromax dosage for chlamydia Washington State University Elson S. Floyd College of Medicine, two tribally-focused nonprofit organizations and 43 tribal nations in the Pacific Northwest.

One goal of RISE is to identify azithromycin zithromax dosage for chlamydia promising AIAN scholars who are pursuing medical careers and recruit them to the Wy’east Post-Baccalaureate pathway at OHSU. The Wy’east pathway offers 10 months of rigorous, structured preparatory curriculum designed to equip citizens and descendants of federally recognized tribes with the knowledge and skills to succeed in medical school.Once students graduate from Wy’east, and meet eligibility criteria, they are guaranteed medical school acceptance by either UC Davis, OHSU, or Washington State University. The collaboration is supported by a nearly $1 million, five-year grant from the federal government’s Indian Health Service.Two students who were identified and recruited by UC Davis through a competitive application azithromycin zithromax dosage for chlamydia process will start Wy’east this month.

They are on track to enter the UC Davis School of Medicine in Summer 2022. The cohort of UC Davis Wy’east azithromycin zithromax dosage for chlamydia scholars is expected to grow over the next several years.In addition to RISE, the School of Medicine is part of another partnership with OHSU, called COMPADRE, which aims to expand access to health care between Portland and Sacramento, including in tribal communities.New pathway to enroll 6 medical students per year at UC DavisUnder the new Native American health pathway, UC Davis and UC San Diego will each enroll six students per year in the program as soon as next school year.The schools can use some of the funding for student scholarships. They can also fund housing subsidies in far-away locations where students will be assigned for clinical rotations.“This level of support is really going to allow us to recruit students who we sometimes lose to other universities because of financial reasons,” González-Flores said.Most importantly, the new program will position the School of Medicine to better focus its efforts on reaching a specific demographic and moving closer to health equity.“The ultimate dream,” González-Flores said, “is to have a positive impact in the health of underserved communities in California by recruiting students who are passionate about their communities and giving them the tools and training to go back and serve those same communities.”.

A year ago, in 1000mg zithromax online additional reading August 2020 Rescue, Calif. Resident Sharon Benton received the phone call 1000mg zithromax online that every mother dreads. Kyle Benton was hospitalized for 43 days.Her 18-year-old son Kyle was longboarding with a friend. He was going downhill fast, when he went flying off of his 1000mg zithromax online board.

The back of his skull hit the pavement and he sustained a fracture, six inches wide. He wasn’t wearing a 1000mg zithromax online helmet. His friend called 911 immediately. Paramedics from the El Dorado Hills Fire Department arrived and 1000mg zithromax online he was rushed by ambulance to the UC Davis Pediatric Intensive Care Unit (PICU).The National Safety Council reports that 217,646 people in the United States were treated in hospital emergency rooms for longboarding, skateboarding and hoverboarding injuries in 2020.

The majority (more than 81,000) of those injuries occurred in children ages 5 to 14.‘It broke my heart to see him like that’As a result of his fall, Kyle suffered a traumatic brain injury (TBI), a skull fracture, a subdural hematoma (a buildup of blood on the surface of the brain) and a blood clot in the brain.“You have 1000mg zithromax online to believe in miracles. That’s what Kyle is to us. A walking miracle.”— Sharon BentonAs hours passed, more injuries were 1000mg zithromax online added to the growing list. He had suffered broken vertebrae.

He also had pneumonia, a common complication of severe brain 1000mg zithromax online injury.“When I walked into the doors of this hospital, I had no idea what to expect or when we would be able to bring Kyle home. And, to be honest, if we would be able to bring Kyle home again,” said Sharon Benton.Her first sight of her son in the hospital. Kyle lying still, surrounded 1000mg zithromax online by endless cords attached to monitors. A brace propped his neck into place.

A ventilator was 1000mg zithromax online breathing for him. He was in a medically induced coma.“It broke my heart to see him 1000mg zithromax online like that,” Benton said. €œBut the doctors and nurses were so gifted, compassionate and kind. Our nurses were there for me, cried with me and got me through those difficult days.”Kyle had physical, occupational and speech therapy six days a week while hospitalized.Kyle would remain in that state for 1000mg zithromax online two weeks.

During this time, UC Davis neurosurgeon Orin Bloch successfully performed a decompressive craniectomy, a surgery to remove a portion of his skull to relieve the swelling in his brain. Months later, he would have a cranial reconstruction to re-form the part of 1000mg zithromax online his skull that was removed.Then, slowly, his medical team weaned him from the sedatives and pain medicine. It was a daily balancing act to keep him stable and comfortable but progressing forward.9 safety tips for longboardersLongboarding is a style of skateboarding, using longboards which usually are 42 to 80 inches long compared to 30- to 38-inch-long skateboards. Longboards are flat and build speed when going downhill.The American Academy of Pediatrics advises riders of skateboards and longboards to follow these safety precautions:• Wear a helmet that meets safety 1000mg zithromax online standards.

Look for 1000mg zithromax online a label on the helmet that reads ASTM F1492 or Snell N-94. This means the helmet is specially designed to protect skateboarders, longboarders and roller/inline skaters.• Wear protective gear. Wrist guards, knee and elbow pads, and shoes with flat soles.• Make sure the wheels and hardware are secure before riding.• Be aware of speed wobble, when the board moves from side to side 1000mg zithromax online unexpectedly and causes the rider to fall off. To prevent it, ride forward on the board and crouch.

Longer boards with wheels that are farther apart may be less likely to have speed wobble.• Check local laws before riding 1000mg zithromax online in public. Some cities have rules about where longboards and skateboards can be ridden. Never ride alone or 1000mg zithromax online in low light.• Watch out for holes, rocks and bumpy riding surfaces.• Never ride under the influence of alcohol or drugs.• Use community skateboard parks instead of riding on homemade ramps or jumps. The parks are away from motor vehicle traffic, and ramps are monitored for safety.• Children under age 5 should not ride the boards, and children ages 5-10 should be supervised.Sharon started an online Facebook group, Prayers for Kyle Benton, to update her family and friends regularly about Kyle’s progress.

Soon, she had a global following of thousands of people 1000mg zithromax online she had never met, who were keeping Kyle and her family in their prayers. She 1000mg zithromax online will forever remember Sept. 11, 2020 as the turning point in Kyle’s patient journey. She posted to her Facebook 1000mg zithromax online group, “We have seen many changes in Kyle over the last 18 hours.

His eyes started fluttering. His arms 1000mg zithromax online and legs are moving. They are lowering all meds and respiratory aids. This may take a couple of days, but Kyle is waking up.”On the road to recoveryWhen Kyle came out of his coma, physical, speech and occupational therapy began in the hospital, six days a week.“When our rehab team first met Kyle, he was non-verbal, not comprehending much and 1000mg zithromax online was fed by a tube,” said speech therapist Michelle Ramirez.

€œKyle progressed quickly and was very determined and motivated. He was such a pleasure to have in therapy, always willing to do the hard and boring tasks he knew would make him stronger.” Music 1000mg zithromax online therapy also helped provided much-needed healing for Kyle. An avid musician who plays both piano and guitar, Kyle was able to receive daily visits from music therapist 1000mg zithromax online Tori Steeley. He would play songs with her that he enjoyed.“The first time I met Kyle, his mom showed me videos of him playing music with his friends.

Kyle expressed 1000mg zithromax online concern several times during that visit that he didn’t remember how to play music,” Steeley said. €œMusic therapy was used to find the ways that Kyle could still positively and easily engage in music-making. We realized that although reading or recalling specific musical pieces was frustrating for him, 1000mg zithromax online he easily remembered guitar and piano chords. Music therapy sessions were often spent with Kyle playing Elton John or Beatles songs on guitar and piano, focusing on Kyle’s strengths as a musician.”A walking miracleOn the one-year anniversary of his injury, Kyle Benton celebrated at Disneyland with his family.On Oct.

13, the Benton 1000mg zithromax online family got the miracle they were hoping for. After 43 days of hospitalization, Kyle was discharged from the hospital and was able to walk out 1000mg zithromax online on his own. €œKyle’s recovery is a testament to his determination, his parents’ support and advocacy and his medical team walking alongside him, pushing him each step. We are grateful to be able 1000mg zithromax online to see him make his way now to college,” Ramirez said.

Kyle recently celebrated his 19th birthday. This week, he will be leaving home for Brigham Young 1000mg zithromax online University Idaho, where he will begin his freshman year. These are milestones that the Benton family had dreamed of during Kyle’s long battle and recovery.“We are extremely thankful to everyone who was there to take care of Kyle. From our good friend 1000mg zithromax online Stacy Minnich who was one of his first responders, to the medical staff at UC Davis.

Together, these people and God saved his life,” Benton said. €œYou have to believe 1000mg zithromax online in miracles. That’s what Kyle is to 1000mg zithromax online us. A walking miracle.”The UC Davis School of Medicine will develop a new academic pathway to train students interested in caring for the Native American and Alaskan Native communities, thanks to a boost in state funding.

UC Davis is committed to increasing the number of Native American medical students like Eleanor Adams who came 1000mg zithromax online here from the RISE pathway.The $1.7 million allocation, included in the state budget signed by Gov. Gavin Newsom in July, comes after years of advocacy by the University of California (UC), which has sought to secure money for ongoing and new medical education programs across several campuses.The programs are part of a UC-wide initiative known as PRIME (Programs in Medical Education), which intend to fill the shortage of doctors in medically underserved areas and reduce health disparities. In addition to the funding to create the new Native American PRIME, UC Davis will receive another $1.7 million to bolster its Rural PRIME pathway, which trains students to address health issues in rural communities.“This is a huge, huge win for us,” 1000mg zithromax online said Mark Servis, UC Davis professor of clinical psychiatry and vice dean for medical education at the School of Medicine. €œIt’s an incredible development because we’ve been working on addressing the needs of tribal communities for years, and this positions us as a national leader.

We also have to subsidize our PRIME programs, and this adds the financial resources needed to support these programs.”Reducing health disparities through PRIMEIn all, the state budget is providing nearly $13 million to enable seven UC schools to boost enrollment and start new programs.In 1000mg zithromax online addition to UC Davis, the funding will benefit UC San Diego, UC Riverside, UC Irvine, UCLA, UCSF and UC Berkeley. PRIME was conceived by the UC Office of the President in 2004 to allow medical schools to offer education pathways that include rotations in hospitals and clinics unique to a geographic area or primary care setting.School of Medicine leaders said the new PRIME pathway will be a draw for Native American students who are eager to become doctors and improve the health of Native Americans in California.“The ultimate dream is to have a positive impact in the health of underserved communities in California by recruiting students who are passionate about their communities and giving them the tools and training to go back and serve those same communities.”— Alicia González-Floresexecutive directorUC Davis School of Medicine’s Community Health ScholarsStudies show that students and residents who are passionate about delivering care in medically underserved areas will likely end up working there as physicians.AIAN populations have long experienced more health complications than other groups, including higher death rates from chronic liver disease and cirrhosis, unintentional injuries and chronic lower respiratory diseases, according to Indian Health Services, a federal initiative.Very few AIAN students apply to medical schools in California, and UC Davis wants to help change that.“The mission of our medical education is to address the physician shortage in areas that really need it, and we know that for tribal communities that need is enormous,” said Alicia González-Flores, a UC Davis Health associate professor in internal medicine and executive director of Community Health Scholars, which administers PRIME.UC Davis was selected for the new track in partnership with UC San Diego, which has the largest cohort of Native American students among UC medical schools.Latest in ongoing effort to boost number of Native American doctorsThe UC Davis School of Medicine has made it a priority to recruit Native American students, and students committed to serving AIAN communities in our region, said pediatrician Eric Crossen, a health sciences clinical associate professor and director of the UC Davis Tribal Health Programs.The effort the past several years includes a multi-sector partnership called RISE, or Reimagine Indians into Medicine. It involves two 1000mg zithromax online other universities, Oregon Health &. Science University (OHSU) and Washington State 1000mg zithromax online University Elson S.

Floyd College of Medicine, two tribally-focused nonprofit organizations and 43 tribal nations in the Pacific Northwest. One goal of RISE is to identify promising AIAN scholars who are pursuing medical careers and recruit them to the Wy’east Post-Baccalaureate pathway at OHSU 1000mg zithromax online. The Wy’east pathway offers 10 months of rigorous, structured preparatory curriculum designed to equip citizens and descendants of federally recognized tribes with the knowledge and skills to succeed in medical school.Once students graduate from Wy’east, and meet eligibility criteria, they are guaranteed medical school acceptance by either UC Davis, OHSU, or Washington State University. The collaboration is supported by a 1000mg zithromax online nearly $1 million, five-year grant from the federal government’s Indian Health Service.Two students who were identified and recruited by UC Davis through a competitive application process will start Wy’east this month.

They are on track to enter the UC Davis School of Medicine in Summer 2022. The cohort 1000mg zithromax online of UC Davis Wy’east scholars is expected to grow over the next several years.In addition to RISE, the School of Medicine is part of another partnership with OHSU, called COMPADRE, which aims to expand access to health care between Portland and Sacramento, including in tribal communities.New pathway to enroll 6 medical students per year at UC DavisUnder the new Native American health pathway, UC Davis and UC San Diego will each enroll six students per year in the program as soon as next school year.The schools can use some of the funding for student scholarships. They can also fund housing subsidies in far-away locations where students will be assigned for clinical rotations.“This level of support is really going to allow us to recruit students who we sometimes lose to other universities because of financial reasons,” González-Flores said.Most importantly, the new program will position the School of Medicine to better focus its efforts on reaching a specific demographic and moving closer to health equity.“The ultimate dream,” González-Flores said, “is to have a positive impact in the health of underserved communities in California by recruiting students who are passionate about their communities and giving them the tools and training to go back and serve those same communities.”.

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New York will zithromax treat the flu state Gov http://pomareslawgroup.com/viagra-best-price/. Andrew Cuomo speaks at a news conference on September 08, 2020 in New York City.Spencer Platt | Getty ImagesThe New York Attorney General is investigating whether a will zithromax treat the flu health-care clinic in the state fraudulently obtained buy antibiotics treatment doses and distributed them to the public, Gov. Andrew Cuomo said Monday.Cuomo declined to provide details of the investigation because it's ongoing, but he noted that it involves ParCare Community Health Network, which the will zithromax treat the flu state identified as a provider in Orange County, New York. Parcare allegedly misrepresented itself to the state's department of health to obtain treatment doses, Cuomo said.New York State Health Commissioner Dr. Howard Zucker said in a statement released over the weekend that the clinic may have "diverted [the treatment] to members of the public — contrary to the state's plan to administer it first to frontline healthcare workers, as well as nursing home residents and staffers."Because doses of the treatment are in such short supply, states are rationing the vials out to certain priority groups before they're made more broadly available.ParCare did not immediately return CNBC's request for comment, but the clinic said on Twitter that it will "actively cooperate" with the New York State Department of Health.It's among the first cases of alleged fraud associated with buy antibiotics treatments, but it's unlikely to be the last, Cuomo said, adding that fraud involving a valuable commodity is "almost an inevitable function of human nature.""We want to send a clear signal will zithromax treat the flu to the providers that if you violate the law on these vaccinations, we will find out and you will be prosecuted," Cuomo said Monday at a news briefing.

"You're going to will zithromax treat the flu see more and more of this. The treatment is a valuable commodity and you have many people who want the treatment."New York State Police have been conducting a criminal investigation, Cuomo noted, and will refer the case to New York AG Letitia James, whose office did not return CNBC's request for comment.To send a clear sign to potential treatment scofflaws, Cuomo said he will sign an executive order on Monday delineating the consequences of defrauding the state when it comes to treatment distribution. He said the state may fine violators up to $1 million and the will zithromax treat the flu state will revoke the health-care provider's license to practice in New York."We are very serious about this," he said. "We will find out and it's not worth risking your license, as well as a possible civil and criminal penalty."Cuomo described the penalties as "the strictest in the nation," adding that New York is will zithromax treat the flu taking a "hyper-cautious, hyper-vigilant" approach."We have the penalties in place. We have the safeguards in place, but when you're dealing with thousands of people, and hundreds of organizations, and a valuable commodity, expect a level of fraud," Cuomo said.

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New York 1000mg zithromax online state Gov. Andrew Cuomo speaks at a news conference on September 08, 2020 in New York City.Spencer Platt | Getty ImagesThe New York Attorney General is investigating whether a health-care clinic in the state fraudulently obtained buy antibiotics treatment doses and distributed them to the public, Gov 1000mg zithromax online. Andrew Cuomo said Monday.Cuomo declined to provide details of the investigation because it's ongoing, but he 1000mg zithromax online noted that it involves ParCare Community Health Network, which the state identified as a provider in Orange County, New York. Parcare allegedly misrepresented itself to the state's department of health to obtain treatment doses, Cuomo said.New York State Health Commissioner Dr. Howard Zucker said in a statement released over the weekend that the clinic may have "diverted [the treatment] to members of the public — contrary to the state's plan to administer it first to frontline healthcare workers, as well as nursing home residents and staffers."Because doses of the treatment are in such short supply, states are rationing the vials out to certain priority groups before they're made more broadly available.ParCare did not immediately return CNBC's request for comment, but the clinic said on Twitter that it will "actively cooperate" with the New York State Department of Health.It's among the first cases of alleged fraud associated with buy antibiotics treatments, but it's unlikely to be the last, Cuomo said, adding that fraud involving a valuable commodity is "almost an inevitable function of human nature.""We want to send a clear 1000mg zithromax online signal to the providers that if you violate the law on these vaccinations, we will find out and you will be prosecuted," Cuomo said Monday at a news briefing.

"You're going to 1000mg zithromax online see more and more of this. The treatment is a valuable commodity and you have many people who want the treatment."New York State Police have been conducting a criminal investigation, Cuomo noted, and will refer the case to New York AG Letitia James, whose office did not return CNBC's request for comment.To send a clear sign to potential treatment scofflaws, Cuomo said he will sign an executive order on Monday delineating the consequences of defrauding the state when it comes to treatment distribution. He said the state may fine violators up to $1 million and the state will revoke the 1000mg zithromax online health-care provider's license to practice in New York."We are very serious about this," he said. "We will find out and it's not worth risking your license, as well as a possible civil and criminal penalty."Cuomo described the penalties as "the strictest in the nation," adding that New York is taking a "hyper-cautious, hyper-vigilant" approach."We have the penalties in 1000mg zithromax online place. We have the safeguards in place, but when you're dealing with thousands of people, and hundreds of organizations, and a valuable commodity, expect a level of fraud," Cuomo said.

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Zithromax 100mg

How to zithromax 100mg cite this article:Singh OP. Mental health in diverse India. Need for zithromax 100mg advocacy.

Indian J Psychiatry 2021;63:315-6”Unity in diversity” - That is the theme of India which we are quite proud of. We have zithromax 100mg diversity in terms of geography – From the Himalayas to the deserts to the seas. Every region has its own distinct culture and food.

There are so many varieties of dress and language. There is huge difference between zithromax 100mg the states in terms of development, attitude toward women, health infrastructure, child mortality, and other sociodemographic development indexes. There is now ample evidence that sociocultural factors influence mental health.

Compton and Shim[1] have described in their model of gene environment interaction how public zithromax 100mg policies and social norms act on the distribution of opportunity leading to social inequality, exclusion, poor environment, discrimination, and unemployment. This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and zithromax 100mg early brain insult with low access to health care leads to poor mental health, disease, and morbidity.When we come to the field of mental health, we find huge differences between different states of India.

The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed northern states had more zithromax 100mg of childhood onset disorders.

This may be due to lead toxicity, nutritional status, and perinatal issues. Higher rates of depression zithromax 100mg and anxiety were found in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms.

Marriage was found to be a negative prognostic indicator contrary to the western zithromax 100mg norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders. The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions.

Apart from culture bound syndromes, the role of cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1–5 lakhs, it was 41,197, and in higher income group, it was 4726 zithromax 100mg. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these require sustained advocacy aimed at promoting rights of mentally ill persons and reducing stigma and zithromax 100mg discriminations.

It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population. Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and pathways should be to build technical evidence for mapping out the problem, cost-effective interventions, and their efficacy.Advocacy can be done at institutional level, organizational zithromax 100mg level, and individual level.

There has been huge work done in this regard at institution level. Important research work done in this regard includes the National Mental Health Survey, National Survey on Extent and Pattern zithromax 100mg of Substance Use in India, Global Burden of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers.

Similarly, at organizational level, the Indian Psychiatric Society (IPS) has filed a case for lacunae in Mental zithromax 100mg Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from “Mental Hai Kya” to “Judgemental Hai Kya.” In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality. The IPS has also started helplines at different levels and media interactions.

The Indian Journal of Psychiatry has also come out with editorials highlighting the need of care of zithromax 100mg marginalized population such as migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy is economic inequality, our weapon is zithromax 100mg research highlighting the role of these factors on mental health.

References 1.Compton MT, Shim RS. The social zithromax 100mg determinants of mental health. Focus 2015;13:419-25.

2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al. National Mental zithromax 100mg Health Survey of India, 2015-16. Prevalence, Patterns and Outcomes.

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

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

The Global Burden of Disease Study 1990–2017. Lancet Psychiatry 2020;7:148-61. 4.National Crime Records Bureau, 2019.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.

How to 1000mg zithromax online cite this article:Singh OP you could try this out. Mental health in diverse India. Need for 1000mg zithromax online advocacy.

Indian J Psychiatry 2021;63:315-6”Unity in diversity” - That is the theme of India which we are quite proud of. We have diversity in terms of geography – From the Himalayas to the deserts to 1000mg zithromax online the seas. Every region has its own distinct culture and food.

There are so many varieties of dress and language. There is huge difference 1000mg zithromax online between the states in terms of development, attitude toward women, health infrastructure, child mortality, and other sociodemographic development indexes. There is now ample evidence that sociocultural factors influence mental health.

Compton and Shim[1] have described in their model of gene environment interaction how public policies and social norms act on the distribution of opportunity leading to 1000mg zithromax online social inequality, exclusion, poor environment, discrimination, and unemployment. This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and early brain insult with low access to health care leads to poor mental health, disease, and morbidity.When we come to 1000mg zithromax online the field of mental health, we find huge differences between different states of India.

The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed northern states had more of childhood onset disorders 1000mg zithromax online.

This may be due to lead toxicity, nutritional status, and perinatal issues. Higher rates of depression and anxiety were found in females 1000mg zithromax online. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms.

Marriage was found to be a negative prognostic indicator contrary to the western norms.[3]Cultural 1000mg zithromax online influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders. The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions.

Apart from culture bound syndromes, the role of 1000mg zithromax online cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1–5 lakhs, it was 41,197, and in higher income group, it was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these 1000mg zithromax online require sustained advocacy aimed at promoting rights of mentally ill persons and reducing stigma and discriminations.

It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population. Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved 1000mg zithromax online and pathways should be to build technical evidence for mapping out the problem, cost-effective interventions, and their efficacy.Advocacy can be done at institutional level, organizational level, and individual level.

There has been huge work done in this regard at institution level. Important research work done in this regard includes the National Mental 1000mg zithromax online Health Survey, National Survey on Extent and Pattern of Substance Use in India, Global Burden of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers.

Similarly, at organizational level, 1000mg zithromax online the Indian Psychiatric Society (IPS) has filed a case for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from “Mental Hai Kya” to “Judgemental Hai Kya.” In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality. The IPS has also started helplines at different levels and media interactions.

The Indian Journal of Psychiatry has also come out with editorials highlighting 1000mg zithromax online the need of care of marginalized population such as migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy is economic inequality, 1000mg zithromax online our weapon is research highlighting the role of these factors on mental health.

References 1.Compton MT, Shim RS. The social determinants 1000mg zithromax online of mental health. Focus 2015;13:419-25.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.