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Nurses at zithromax z pak 250mg tablet http://keim-farben.de/can-you-buy-over-the-counter-amoxil/ St. Vincent Hospital in Worcester, Massachusetts, voted to approve a new contract Monday, ending a strike that has kept them on the picket line for 301 days.The Massachusetts Nurses Association, which represents the 700 striking nurses, reached a tentative agreement with Tenet Healthcare, the hospital's Dallas-based parent company, on Dec. 17.

Union members have now ratified that deal on a vote with 487 in favor and nine against. The contract is retroactively effective to Jan. 3, 2021 and runs through Dec.

31, 2025. Nurses have been without a contract since the end of 2019.Under the agreement, nurses can return to their previous positions within 30 days and Tenet Healthcare agreed to safer working conditions, the union announced in a news release. St.

Vincent Hospital also will retain all the permanent replacement nurses it hired during the months-long strike."This has been a long and arduous struggle by 700 courageous caregivers who put everything on the line to achieve the improvements we need to ensure optimum patient care," Marlena Pellegrino, a nurse at the hospital and co-chair of the Massachusetts Nurses Association's local bargaining unit, said in a news release."The new contract will provide enhancements for patients and our team, and we are glad to finally end the strike and put our sole focus back on patient care," St. Vincent Hospital CEO Carolyn Jackson said in a news release. "We will be setting a new tone at St.

Vincent Hospital. We are one team with a common purpose. Not striking nurses versus replacement nurses.

1, 2021, and back pay for the past two years dating to the end of the previous collective bargaining agreement.The contract also adds two nurses to the Hospital Workforce Safety Committee to represent nurses on workplace violence and it requires the hospital to maintain a metal detector in the emergency department and to provide additional police staffing at nights, on weekends and on holidays.Negotiators reached the tentative deal last month following two weeks of federal mediation. The labor action commenced last March after two years of two years of talks failed to produce an agreement between Tenet Healthcare and the nurses union. The strike was the longest by nurses in state history and the longest nationally in more than 15 years, according to the Massachusetts Nurses Association.Four Massachusetts congressional Democrats questioned how Tenet Healthcare was using its buy antibiotics relief funds last June, given the strike over staffing levels.

And National Nurses United has asked the Federal Trade Commission to investigate what it calls "exploitative" contracts for new nurses at Tenet Healthcare and two other health systems."With this agreement we can go back into that building with great pride not just in what we got in writing in the agreement, but for what we have built together as nurses who know they did everything they could for their patients and their community," Dominique Muldoon, a nurse at the hospital and co-chair of the bargaining unit, said in a news release..

Nurses at St buy zithromax online. Vincent Hospital in Worcester, Massachusetts, voted to approve a new contract Monday, ending a strike that has kept them on the picket line for 301 days.The Massachusetts Nurses Association, which represents the 700 striking nurses, reached a tentative agreement with Tenet Healthcare, the hospital's Dallas-based parent company, on Dec. 17. Union members have now ratified that deal on a vote with 487 in favor and nine against. The contract is retroactively effective to Jan.

3, 2021 and runs through Dec. 31, 2025. Nurses have been without a contract since the end of 2019.Under the agreement, nurses can return to their previous positions within 30 days and Tenet Healthcare agreed to safer working conditions, the union announced in a news release. St. Vincent Hospital also will retain all the permanent replacement nurses it hired during the months-long strike."This has been a long and arduous struggle by 700 courageous caregivers who put everything on the line to achieve the improvements we need to ensure optimum patient care," Marlena Pellegrino, a nurse at the hospital and co-chair of the Massachusetts Nurses Association's local bargaining unit, said in a news release."The new contract will provide enhancements for patients and our team, and we are glad to finally end the strike and put our sole focus back on patient care," St.

Vincent Hospital CEO Carolyn Jackson said in a news release. "We will be setting a new tone at St. Vincent Hospital. We are one team with a common purpose. Not striking nurses versus replacement nurses.

Not nurses versus management. One team united behind the principles of professionalism, excellence, accountability and compassion."Under the agreement, Tenet Healthcare agreed to maintain specific staffing levels and ratios in different departments and to limit flex staffing, which allows the hospital to send nurses home when patients volume is low, according to the the nurses union. Nurses will get 2% raises each year of the contract, retroactive to Jan. 1, 2021, and back pay for the past two years dating to the end of the previous collective bargaining agreement.The contract also adds two nurses to the Hospital Workforce Safety Committee to represent nurses on workplace violence and it requires the hospital to maintain a metal detector in the emergency department and to provide additional police staffing at nights, on weekends and on holidays.Negotiators reached the tentative deal last month following two weeks of federal mediation. The labor action commenced last March after two years of two years of talks failed to produce an agreement between Tenet Healthcare and the nurses union.

The strike was the longest by nurses in state history and the longest nationally in more than 15 years, according to the Massachusetts Nurses Association.Four Massachusetts congressional Democrats questioned how Tenet Healthcare was using its buy antibiotics relief funds last June, given the strike over staffing levels. And National Nurses United has asked the Federal Trade Commission to investigate what it calls "exploitative" contracts for new nurses at Tenet Healthcare and two other health systems."With this agreement we can go back into that building with great pride not just in what we got in writing in the agreement, but for what we have built together as nurses who know they did everything they could for their patients and their community," Dominique Muldoon, a nurse at the hospital and co-chair of the bargaining unit, said in a news release..

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Key takeaways Most Americans under the age of 65 get their health insurance allergic to zithromax what can i take from an employer. This makes life fairly allergic to zithromax what can i take simple as long as you have a job that provides solid health benefits. All you need to do is enroll when youâre eligible, and if your allergic to zithromax what can i take employer offers a few options from which to choose, pick the one that best fits your needs each year during your employerâs annual enrollment period.But the downside to having health insurance linked to employment is that losing your job will also mean losing your health insurance, adding stress to an already stressful situation.The good news is that youâve got options â probably several, depending on the circumstances. Letâs take a look at what you need to know about health insurance if youâve lost your job and are facing the loss of your employer-sponsored health coverage.Can I enroll in self-purchased insurance as soon as Iâve lost my job?.

Open enrollment for 2022 health allergic to zithromax what can i take insurance runs through at least January 15, in most states. But if allergic to zithromax what can i take youâre losing your job-based health insurance after that, you do not have to wait for the next annual open enrollment period to sign up for a new ACA-compliant plan. Youâll qualify for your own special enrollment period due to the loss of your employer-sponsored health plan.This will allow you to enroll in a plan through the marketplace/exchange and take advantage of the subsidies that are bigger than ever, thanks to the American Rescue Plan.If you enroll prior to your coverage loss, your new plan will take effect the first of the month after your old plan ends, which means youâll have seamless coverage if your old plan is ending on the last day of the month.Your special enrollment period also continues for 60 days after your coverage loss, although youâd have a gap in coverage if you wait and enroll after your old plan ends, since your new plan wouldnât take effect retroactively.If youâre in that situation, you might find that a short-term health plan is a good option for bridging the gap until your new plan takes effect. Short-term plans wonât cover pre-existing conditions and are not allergic to zithromax what can i take regulated by the Affordable Care Act (ACA).

But they can provide fairly good coverage for unexpected medical needs during a temporary window when youâd otherwise be uninsured.COBRA (or state continuation) versus self-purchased coverageAlternatively, if COBRA is available, you have 60 days to decide whether you want allergic to zithromax what can i take to take it or not. You can use this window as a bit of a cushion between your old coverage and your new coverage, because COBRA takes effect retroactively if and when you elect to use it. So if youâll have a one-month gap between your job plan ending and your allergic to zithromax what can i take new plan starting, you could elect COBRA if you end up with medical needs during that month. The coverage would seamlessly start when your old plan would have ended, avoiding any gap in coverage as long as you pay all COBRA allergic to zithromax what can i take premiums that are due.If COBRA (or state continuation coverage) is available, your employer will notify you and give you information about what youâll need to do to activate the coverage continuation, how long you can keep it, and how much youâll have to pay each month to keep the coverage in force.If you rely on COBRA after leaving your job (instead of transitioning to a self-purchased plan in the marketplace), youâll have a special enrollment period when the COBRA subsidy ends.

This will allow you to transition to an individual/family plan at that point if you want to.COBRA coverage vs individual-market health insuranceHereâs what to keep in mind when youâre deciding between COBRA and an individual-market health plan:ACA marketplace subsidies are now available at all income levels, depending on the cost of coverage in your area (the American Rescue Plan eliminated the income cap for subsidy eligibility for 2021 and 2022). And the subsidies are substantial, covering the majority of the premium cost for the majority of marketplace allergic to zithromax what can i take enrollees. Unless your employer is subsidizing your COBRA coverage, youâll probably find that the monthly premiums are lower if you enroll in a plan allergic to zithromax what can i take through the marketplace, as opposed to continuing your employer-sponsored plan.Have you already spent a significant amount of money on out-of-pocket costs under your employer-sponsored plan this year?. Youâll almost certainly be starting over at $0 if you switch to an individual/family plan, even if itâs offered by the same insurer that provides your employer-sponsored coverage.

Depending on the specifics of your situation, the money youâve already paid for out-of-pocket medical expenses this year could offset the lower premiums youâre likely to see in the allergic to zithromax what can i take marketplace.Do you have certain doctors or medical facilities you need to continue to use?. Youâll want to carefully check the provider networks of the available individual/family plans to see if theyâre in-network (provider networks can vary significantly between the employer-sponsored and individual market, even if allergic to zithromax what can i take the plans are offered by the same insurance company). And if there are specific medications that you need, youâll want to be sure theyâre on the formularies of the plans youâre considering.Will you qualify for a premium subsidy if you switch to an individual/family plan?. If you do qualify, allergic to zithromax what can i take youâll need to shop in your exchange/marketplace, as subsidies are not available if you buy your plan directly from an insurance company.

(You can call the number at the top of this page to be connected with a broker who can help you enroll in a plan through the exchange.) And again, as a result of the ARP, subsidies are larger and more widely available than allergic to zithromax what can i take usual. That will continue to be the case throughout 2022 as well. What if my income is too low allergic to zithromax what can i take for subsidies?. In order to qualify for premium subsidies for a plan purchased in the marketplace, you must not be eligible for Medicaid, premium-free Medicare Part A, or an employer-sponsored plan, and your income has to be at least 100% of the federal poverty level.In most states, the ACAâs expansion of Medicaid eligibility provides coverage to allergic to zithromax what can i take adults with household income up to 138% of the poverty level, with eligibility determined based on current monthly income.

So if your income has suddenly dropped to $0, youâll likely be eligible for Medicaid and could transition to Medicaid when your job-based coverage ends.Unfortunately, there are still 11 states where most adults face a coverage gap if their household income is below the federal poverty level. They arenât eligible for premium subsidies in the marketplace, allergic to zithromax what can i take and also arenât eligible for Medicaid. This is allergic to zithromax what can i take an unfortunate situation that those 11 states have created for their low-income residents. But there are strategies for avoiding the coverage gap if youâre in one of those states.And keep in mind that subsidy eligibility in the marketplace is based on your household income for the whole year, even if your current monthly income is below the poverty level.

So if you earned enough earlier in the year to be subsidy-eligible, you can enroll in allergic to zithromax what can i take a plan with subsidies based on that income, despite the fact that you might not earn anything else for the rest of the year.What if Iâll soon be eligible for Medicare?. There has been an increase recently allergic to zithromax what can i take in the number of people retiring in their late 50s or early 60s, before theyâre eligible for Medicare. The ACA made this a more realistic option starting in 2014, thanks to premium subsidies and the elimination of medical underwriting.And the ARP has boosted subsidies and made them more widely allergic to zithromax what can i take available through the end of 2022, making affordable coverage more accessible for early retirees. Thatâs especially true for those whose pre-retirement income might have made them ineligible for subsidies in the year they retired, due to the âsubsidy cliffâ (which has been eliminated by the ARP through the end of 2022).So if youâre losing your job or choosing to leave it and you still have a few months or a few years before youâll be 65 and eligible for Medicare, rest assured that you wonât have to go uninsured.Youâll be able to sign up for a marketplace plan during your special enrollment period triggered by the loss of your employer-sponsored plan.

And even if you earned a fairly robust income in the earlier part of the year, you might still qualify for premium subsidies to offset some allergic to zithromax what can i take of the cost of your new plan for the rest of the year.And marketplace plans are always purchased on a month-to-month basis, so youâll be able to cancel your coverage when you eventually transition to Medicare, regardless of when that happens.Donât worry, get coveredThe short story on all of this?. Coverage is available, and obtaining your own health allergic to zithromax what can i take plan isnât as complicated as it might seem at first glance, even if youâve had employer-sponsored coverage all your life.You can sign up outside of open enrollment if youâre losing your job-based insurance, and thereâs a good chance youâll qualify for financial assistance that will make your new plan affordable.You can learn more about the marketplace in your state and the available plan options by selecting your state on this map. And there are zero-cost enrollment assisters â Navigators and brokers â available throughout the country to help you make sense of it all.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act allergic to zithromax what can i take for healthinsurance.org.

Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.Key takeaways The Biden administration allergic to zithromax what can i take announced last week that enrollment in ACA marketplace plans had reached an all-time high of 13.6 million* as of December 15, with a month still to go in the open enrollment period (OEP) for 2022 in most states.Thatâs an increase of about 2 million (17%) over enrollment as of the same date last year, according to Charles Gabaâs estimate, and well above the previous high of 12.7 million recorded as of the end of open enrollment for 2016, which lasted until January 31 in most states. When OEP ends this coming January, enrollment in marketplace plans will exceed 14 million.92% of marketplace enrollees in HealthCare.gov states received health insurance subsidiesIn the 33 states using the federal exchange, HealthCare.gov (for which the federal government provides more detailed statistics than in the 18 state-based exchanges), almost all enrollees (92%) received premium tax credits (subsidies) to help pay for coverage â including 400,000 who would not have qualified for subsidies prior to passage in March of this year of the American Rescue Plan (ARP). That bill not only increased premium subsidies at every income level through 2022, but also removed the previous income cap on subsidies, which was 400% of the federal poverty level (FPL) ($51,520 per year for an individual and $106,000 allergic to zithromax what can i take for a family of four). In 2022, no enrollee who lacks access to other affordable insurance pays more than 8.5% of income for a allergic to zithromax what can i take benchmark Silver plan (the second cheapest Silver plan in each area), and most pay far less.The enrollment increase is tribute to the huge boost in affordability created by the ARP subsidies.

A benchmark Silver plan with strong Cost Sharing Reduction (CSR, attached to Silver plans for low-income enrollees) is now free at incomes up to 150%FPL ($19,320 for an individual, $39,750 for a family of four in 2022) and costs no more than 2% of income ($43/month for an individual) at incomes up to 200% FPL. The percentage of income allergic to zithromax what can i take required for the benchmark Silver plan was reduced at higher incomes as well. The ARP also provided free high-CSR Silver coverage to anyone who received any unemployment insurance income in 2021.The American Rescue Plan boosted enrollment throughout 2021 and into 2022The enrollment gains during OEP build on the enrollment surge triggered by the emergency special enrollment period (SEP) opened by the Biden administration on February 15 of this year, which ran through August 15 in the 33 states using HealthCare.gov, and for varying periods in the allergic to zithromax what can i take 15 states that ran their own exchanges in 2021. (There are now 18 state-based exchanges, as Kentucky, Maine and New Mexico launched new ones for 2022.)The ARP subsidies came online in April (or May in a few state marketplaces).

From February to August, 2.8 million people enrolled during the SEP, and total enrollment increased by 900,000 on net from February to August (as people also disenrolled every month, and many enrollees allergic to zithromax what can i take doubtless regained employer-sponsored coverage during a period of rapid job growth).In addition, once the ARP subsidy increases went into effect, 8 million existing enrollees saw their premiums reduced by an average of 50%, from $134 to $67 per month. Enrolleesâ premiums in 2022 should be similar to those of the SEP.Enrollment growth was concentrated in states that have not expanded MedicaidEnrollment increases during open enrollment â allergic to zithromax what can i take as during the SEP and the OEP for 2021 â were heavily concentrated in states that have not enacted the ACA expansion of Medicaid eligibility. There were 14 such states during most of the SEP and 12 during the (still current) OEP, as Oklahoma belatedly enacted the Medicaid expansion starting in July of this year, and Missouri in October.In non-expansion states, eligibility for ACA premium subsidies begins at 100% FPL, while in states that have enacted the expansion, marketplace subsidy eligibility begins at 138% FPL, and Medicaid is available below that threshold. In non-expansion allergic to zithromax what can i take states, the marketplace is the only route to coverage for most low-income adults, and those who report incomes below 100% FPL mostly get no help at all â they are in the notorious coverage gap.

In those states, about 40% of marketplace enrollees have incomes below 138% FPL â that is, they would be enrolled in Medicaid if allergic to zithromax what can i take their states enacted the expansion.During OEP, these 12 non-expansion states account for 81% of the enrollment gains in the 33 HealthCare.gov states, and about two-thirds of enrollment gains in all states. The table below also shows gains over a two-year period, encompassing the effects of the buy antibiotics zithromax.Total plan selections in non-expansion states**Dec. 15 open enrollment snapshots 2020-2022State202020212022Increase 2021-2022% increase allergic to zithromax what can i take 2021-2022Increase 2020-2022% increase 2020-2022Alabama159,820168,399205,40737,00822.0%45,58728.5%Florida1,912,3942,115,4242,592,906477,48222.6%680,51235.6%Georgia464,041541,641653,999139,35827.1%189,95840.9%Kansas85,88088,497102,57314,07615.9%16,69319.4%Mississippi98,868110,519132,43221,91319.8%33,56433.9%North Carolina505,159536,270638,309102,03919.0%133,15026.4%South Carolina215,331230,033282,88252,84923.0%67,55131.4%South Dakota29,33031,28339,2928,00925.6%9,96234.0%Tennessee200,723211,474257,77846,30421.9%57,05528.4%Texas1,117,8821,284,5241,711,204426,68033.2%593,32253.1%Wisconsin196,594192,183205,99113,8087.2%9,3974.8%Wyoming24,66526,68433,0356,35123.8%8,37033.9%Non-expansion states5,010,6875,509,9316,855,8081,345,87724.4%1,845,12136.8%All HC.gov states7,533,9368,053,8429,724,2511,670,40920.7%2,190,31529.1%In the 39 states that have enacted the ACA Medicaid expansion (21 on HealthCare.gov and 18 running their own exchanges), far fewer enrollees are eligible for free Silver coverage. In expansion states, eligibility for marketplace subsidies begins at an income allergic to zithromax what can i take of 138% FPL, as people below that threshold are eligible for Medicaid.

Nevertheless, enrollment growth in non-expansion states during the current OEP is substantial, increasing by about 755,000 year-over-year, or 13%.The marketplace has been a zithromax âsafety netâThe marketplace has been a bulwark against uninsurance during the zithromax, among low-income people especially and in the non-expansion states in particular. As shown allergic to zithromax what can i take in the chart above, enrollment in these 11 states increased by 1.8 million from Dec. 15, 2019 to Dec allergic to zithromax what can i take. 15, 2021 â a 37% increase.

For all states, the two-year increase is in the neighborhood of 25% and will approach 3 million (from 11.4 million in OEP for 2020 to above 14 million when OEP for 2022 ends in January) allergic to zithromax what can i take. Thatâs in addition to an increase of more than 12 million in Medicaid enrollment during the zithromax.While millions of Americans lost jobs when the zithromax struck, and millions fewer are employed today than in February 2020, the uninsured rate did not increase during 2020, according to government surveys, and may even prove to have downticked during 2021 or 2022 when the data comes in.While the government has not yet published detailed statistics as to who has enrolled allergic to zithromax what can i take during the current OEP, they did do so in the final enrollment report for the emergency SEP. During the emergency SEP, out of 2.8 million new enrollees, 2.1 million were in the 33 HealthCare.gov states allergic to zithromax what can i take. In those states, 41% of enrollees obtained Silver plans with the highest level of CSR, which means that they had incomes under 150% FPL (or received unemployment income) and so received free coverage in plans with an actuarial value of 94% â far above the norm for employer-sponsored plans.The median deductible obtained in HealthCare.gov states was $50, which makes sense, as 54% of enrollees obtained Silver plans with strong CSR, raising the planâs actuarial value to either 94% (at incomes up to 150% FPL) or to 87% (at incomes between 150% and 200% FPL).

Two-thirds of enrollees in HealthCare.gov states paid less than $50 per month for coverage, and 37% obtained coverage for free.At higher incomes, as noted above, 400,000 enrollees who received subsidies in HealthCare.gov states would not have been subsidy-eligible before the ARP lifted the income cap on subsidies (previously 400% FPL) allergic to zithromax what can i take. The same is also doubtless true allergic to zithromax what can i take for several hundred thousand enrollees in state-based marketplaces. The SBEs account for a bit less than a third of all enrollment, but in those states, all of which have expanded Medicaid, the percentage of enrollees with income over 400% FPL is almost twice that of the HealthCare.gov states (12% versus 7% during the emergency SEP).ARP. A patch allergic to zithromax what can i take for the coverage gap?.

The strong enrollment growth in non-expansion states â an increase of 37% in two years â indicates that during the zithromax, some low-income people in those states found their way out of the coverage gap (caused by the lack of government help available to most adults with incomes below allergic to zithromax what can i take 100% FPL). In March 2020, the CARES Act (H.R.748) provided supplementary uninsurance income of $600 per week for up to four months to a wide range of people who had lost income during the zithromax, likely pushing many incomes over 100% FPL. In 2021, anyone who received any unemployment income qualified for free Silver coverage, and allergic to zithromax what can i take during the emergency SEP, 84,000 new enrollees took advantage of this provision (along with 124,000 existing enrollees). That emergency provision is not in effect in allergic to zithromax what can i take 2022, however.Marketplace subsidies are based on an estimate of future income.

For low-income people in particular, who are often paid by the hour, work uncertain schedules, depend on tips, or are self-employed, income can be difficult to project. The desire to be insured allergic to zithromax what can i take during the zithromax may have spurred some applicants to make sure their estimates cleared the 100% FPL threshold. (Enrollment assisters and brokers can help applicants deploy every resource to meet this goal.)For OEP 2022, the allergic to zithromax what can i take Biden administration raised funding for nonprofit enrollment assistance in HealthCare.gov states to record levels, enough to train and certify more than 1,500 enrollment navigators. This past spring, in compliance with a court order, the exchanges stopped requiring low-income applicants who estimated income over 100% FPL to provide documentation if the governmentâs âtrusted sourcesâ of information indicated an income below the threshold.Comparatively weak enrollment growth in Wisconsin may support the hypothesis that under pressure of the zithromax, some enrollees in other non-expansion states are climbing out of the coverage gap.

Alone among non-expansion states, Wisconsin has no coverage gap, as the state provides Medicaid to adults with incomes up to 100% FPL (rather than up to the 138% allergic to zithromax what can i take FPL threshold required by the ACA Medicaid expansion, which offers enhanced federal funding to participating states). In Wisconsin, those whose income falls below the 100% FPL marketplace eligibility threshold have access to allergic to zithromax what can i take free coverage. Wisconsin is the only non-expansion state that did not experience double-digit enrollment growth in OEP 2022 or from 2020-2022.The future of increased subsidies is unclearThe American Rescue Plan was conceived as emergency zithromax relief, and its increased subsidies run only through 2022. President Bidenâs Build Back Better bill, which passed in the House of Representatives but is currently stalled in the Senate, would extend the ARP subsidies allergic to zithromax what can i take through 2025 or possibly further.The large increase in enrollment this year should add pressure on Congress to extend the improved subsidies into future years.

Consumer response to the increased subsidies has proved allergic to zithromax what can i take immediate and dramatic. The ARP subsidy boosts brought the Affordable Care Act much closer than previously to living up to the promise of âaffordableâ care expressed in its name. Going backwards on that promise should not be seen as a allergic to zithromax what can i take politically viable or ethical path.* * ** Another million people are enrolled in Basic Health Programs established under the ACA by Minnesota and New York â low-cost, Medicaid-like programs for state residents with incomes under 200% FPL. Enrollment in these programs is on track to increase by 13% this year, according to Charles Gabaâs estimate.** HealthCare.gov all-state allergic to zithromax what can i take totals are for the 33 states using the federal exchange this year.

Source. Charles Gaba, OE snapshots as allergic to zithromax what can i take of mid-December, 2021-22, 2020-2021. See also CMS end-of-OEP snapshots for 2020, 2021, 2022 Andrew Sprung allergic to zithromax what can i take is a freelance writer who blogs about politics and healthcare policy at xpostfactoid. His articles about the Affordable Care Act have appeared in publications including The American Prospect, Health Affairs, The Atlantic, and The New Republic.

He is the winner of the National Institute of Health Care Managementâs 2016 Digital Media Award. He holds a Ph.D. In English literature from the University of Rochester..

Key takeaways Most Americans buy zithromax online under the age of 65 get their health Levitra for sale near me insurance from an employer. This makes life fairly simple as long as you have a job that buy zithromax online provides solid health benefits. All you need to do is enroll when youâre eligible, and if your employer offers a few options from which buy zithromax online to choose, pick the one that best fits your needs each year during your employerâs annual enrollment period.But the downside to having health insurance linked to employment is that losing your job will also mean losing your health insurance, adding stress to an already stressful situation.The good news is that youâve got options â probably several, depending on the circumstances. Letâs take a look at what you need to know about health insurance if youâve lost your job and are facing the loss of your employer-sponsored health coverage.Can I enroll in self-purchased insurance as soon as Iâve lost my job?. Open enrollment for 2022 health insurance runs through buy zithromax online at least January 15, in most states.

But if youâre losing your job-based health insurance after that, you do not have to buy zithromax online wait for the next annual open enrollment period to sign up for a new ACA-compliant plan. Youâll qualify for your own special enrollment period due to the loss of your employer-sponsored health plan.This will allow you to enroll in a plan through the marketplace/exchange and take advantage of the subsidies that are bigger than ever, thanks to the American Rescue Plan.If you enroll prior to your coverage loss, your new plan will take effect the first of the month after your old plan ends, which means youâll have seamless coverage if your old plan is ending on the last day of the month.Your special enrollment period also continues for 60 days after your coverage loss, although youâd have a gap in coverage if you wait and enroll after your old plan ends, since your new plan wouldnât take effect retroactively.If youâre in that situation, you might find that a short-term health plan is a good option for bridging the gap until your new plan takes effect. Short-term plans buy zithromax online wonât cover pre-existing conditions and are not regulated by the Affordable Care Act (ACA). But they can provide fairly good coverage for unexpected medical needs during a temporary window when youâd otherwise be uninsured.COBRA (or state continuation) buy zithromax online versus self-purchased coverageAlternatively, if COBRA is available, you have 60 days to decide whether you want to take it or not. You can use this window as a bit of a cushion between your old coverage and your new coverage, because COBRA takes effect retroactively if and when you elect to use it.

So if youâll have a one-month gap between your job plan ending and your new plan starting, you buy zithromax online could elect COBRA if you end up with medical needs during that month. The coverage would seamlessly start when your old plan would have ended, avoiding any gap in coverage as long as you pay all COBRA premiums that are due.If COBRA (or state continuation coverage) is available, your employer will notify you and give you information about what youâll need to do to activate the coverage continuation, how long you buy zithromax online can keep it, and how much youâll have to pay each month to keep the coverage in force.If you rely on COBRA after leaving your job (instead of transitioning to a self-purchased plan in the marketplace), youâll have a special enrollment period when the COBRA subsidy ends. This will allow you to transition to an individual/family plan at that point if you want to.COBRA coverage vs individual-market health insuranceHereâs what to keep in mind when youâre deciding between COBRA and an individual-market health plan:ACA marketplace subsidies are now available at all income levels, depending on the cost of coverage in your area (the American Rescue Plan eliminated the income cap for subsidy eligibility for 2021 and 2022). And the subsidies are substantial, covering the majority of the buy zithromax online premium cost for the majority of marketplace enrollees. Unless your employer is subsidizing your COBRA coverage, youâll probably find that the monthly premiums are lower if you enroll in a plan through the marketplace, as opposed to continuing your employer-sponsored plan.Have you already spent a significant amount of money on out-of-pocket costs under your buy zithromax online employer-sponsored plan this year?.

Youâll almost certainly be starting over at $0 if you switch to an individual/family plan, even if itâs offered by the same insurer that provides your employer-sponsored coverage. Depending on the specifics of your situation, the money youâve already paid for out-of-pocket medical expenses this year could offset the lower premiums youâre likely to see in the marketplace.Do buy zithromax online you have certain doctors or medical facilities you need to continue to use?. Youâll buy zithromax online want to carefully check the provider networks of the available individual/family plans to see if theyâre in-network (provider networks can vary significantly between the employer-sponsored and individual market, even if the plans are offered by the same insurance company). And if there are specific medications that you need, youâll want to be sure theyâre on the formularies of the plans youâre considering.Will you qualify for a premium subsidy if you switch to an individual/family plan?. If you do qualify, youâll need to shop in your exchange/marketplace, as subsidies are not available if you buy your buy zithromax online plan directly from an insurance company.

(You can call the number at the top of this page to be connected with a broker who can help you enroll in a plan through the exchange.) And again, as a result of the ARP, subsidies are larger and more widely available buy zithromax online than usual. That will continue to be the case throughout 2022 as well. What if my buy zithromax online income is too low for subsidies?. In order to qualify for premium subsidies for a plan purchased in the marketplace, you must not be eligible for Medicaid, premium-free Medicare Part A, or an employer-sponsored plan, and your income has to be at least 100% of the federal poverty level.In most states, the ACAâs expansion of Medicaid eligibility provides coverage to adults with household income up to 138% of the poverty level, with eligibility determined buy zithromax online based on current monthly income. So if your income has suddenly dropped to $0, youâll likely be eligible for Medicaid and could transition to Medicaid when your job-based coverage ends.Unfortunately, there are still 11 states where most adults face a coverage gap if their household income is below the federal poverty level.

They arenât eligible for premium subsidies in the marketplace, and also arenât buy zithromax online eligible for Medicaid. This is buy zithromax online an unfortunate situation that those 11 states have created for their low-income residents. But there are strategies for avoiding the coverage gap if youâre in one of those states.And keep in mind that subsidy eligibility in the marketplace is based on your household income for the whole year, even if your current monthly income is below the poverty level. So if you earned enough earlier in the buy zithromax online year to be subsidy-eligible, you can enroll in a plan with subsidies based on that income, despite the fact that you might not earn anything else for the rest of the year.What if Iâll soon be eligible for Medicare?. There has buy zithromax online been an increase recently in the number of people retiring in their late 50s or early 60s, before theyâre eligible for Medicare.

The ACA made this a more realistic option starting in 2014, thanks to premium subsidies and the elimination of medical underwriting.And the ARP has boosted subsidies and made them more widely available through the end of 2022, making buy zithromax online affordable coverage more accessible for early retirees. Thatâs especially true for those whose pre-retirement income might have made them ineligible for subsidies in the year they retired, due to the âsubsidy cliffâ (which has been eliminated by the ARP through the end of 2022).So if youâre losing your job or choosing to leave it and you still have a few months or a few years before youâll be 65 and eligible for Medicare, rest assured that you wonât have to go uninsured.Youâll be able to sign up for a marketplace plan during your special enrollment period triggered by the loss of your employer-sponsored plan. And even if you earned a fairly robust income in the earlier part of the year, you might still qualify for premium subsidies to offset some of the cost of your new plan for the rest of the year.And marketplace plans are always purchased on a month-to-month basis, so youâll be able buy zithromax online to cancel your coverage when you eventually transition to Medicare, regardless of when that happens.Donât worry, get coveredThe short story on all of this?. Coverage is available, and obtaining your own health plan isnât as complicated as it might seem at first glance, even if youâve had employer-sponsored coverage all your life.You can sign up outside of open enrollment if youâre losing your job-based insurance, and buy zithromax online thereâs a good chance youâll qualify for financial assistance that will make your new plan affordable.You can learn more about the marketplace in your state and the available plan options by selecting your state on this map. And there are zero-cost enrollment assisters â Navigators and brokers â available throughout the country to help you make sense of it all.Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006.

She has written dozens of opinions and educational pieces about the Affordable Care Act for buy zithromax online healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.Key takeaways The Biden administration announced last week that enrollment in ACA marketplace plans had reached an all-time high of 13.6 million* as of December 15, with a month still to go in the open enrollment period (OEP) for 2022 in most states.Thatâs an increase of about 2 million (17%) over enrollment as buy zithromax online of the same date last year, according to Charles Gabaâs estimate, and well above the previous high of 12.7 million recorded as of the end of open enrollment for 2016, which lasted until January 31 in most states. When OEP ends this coming January, enrollment in marketplace plans will exceed 14 million.92% of marketplace enrollees in HealthCare.gov states received health insurance subsidiesIn the 33 states using the federal exchange, HealthCare.gov (for which the federal government provides more detailed statistics than in the 18 state-based exchanges), almost all enrollees (92%) received premium tax credits (subsidies) to help pay for coverage â including 400,000 who would not have qualified for subsidies prior to passage in March of this year of the American Rescue Plan (ARP). That bill not only increased premium subsidies at every income level through 2022, but also removed the previous income cap on subsidies, which was 400% of the buy zithromax online federal poverty level (FPL) ($51,520 per year for an individual and $106,000 for a family of four). In 2022, no enrollee who lacks access to other affordable insurance pays more than 8.5% of income for a benchmark Silver buy zithromax online plan (the second cheapest Silver plan in each area), and most pay far less.The enrollment increase is tribute to the huge boost in affordability created by the ARP subsidies.

A benchmark Silver plan with strong Cost Sharing Reduction (CSR, attached to Silver plans for low-income enrollees) is now free at incomes up to 150%FPL ($19,320 for an individual, $39,750 for a family of four in 2022) and costs no more than 2% of income ($43/month for an individual) at incomes up to 200% FPL. The percentage of income required for the benchmark buy zithromax online Silver plan was reduced at higher incomes as well. The ARP also buy zithromax online provided free high-CSR Silver coverage to anyone who received any unemployment insurance income in 2021.The American Rescue Plan boosted enrollment throughout 2021 and into 2022The enrollment gains during OEP build on the enrollment surge triggered by the emergency special enrollment period (SEP) opened by the Biden administration on February 15 of this year, which ran through August 15 in the 33 states using HealthCare.gov, and for varying periods in the 15 states that ran their own exchanges in 2021. (There are now 18 state-based exchanges, as Kentucky, Maine and New Mexico launched new ones for 2022.)The ARP subsidies came online in April (or May in a few state marketplaces). From February to August, 2.8 million people enrolled during the SEP, and total enrollment increased by 900,000 on net from February to August (as people also disenrolled every month, and many enrollees doubtless regained employer-sponsored coverage during a period of rapid job growth).In addition, once the ARP subsidy increases went into effect, 8 million existing enrollees saw their premiums reduced by an average of 50%, from $134 to $67 per buy zithromax online month.

Enrolleesâ premiums in 2022 should be similar to those of the SEP.Enrollment growth was concentrated in states that have not expanded MedicaidEnrollment increases during open enrollment â as during the buy zithromax online SEP and the OEP for 2021 â were heavily concentrated in states that have not enacted the ACA expansion of Medicaid eligibility. There were 14 such states during most of the SEP and 12 during the (still current) OEP, as Oklahoma belatedly enacted the Medicaid expansion starting in July of this year, and Missouri in October.In non-expansion states, eligibility for ACA premium subsidies begins at 100% FPL, while in states that have enacted the expansion, marketplace subsidy eligibility begins at 138% FPL, and Medicaid is available below that threshold. In non-expansion states, the marketplace buy zithromax online is the only route to coverage for most low-income adults, and those who report incomes below 100% FPL mostly get no help at all â they are in the notorious coverage gap. In those states, about 40% of marketplace enrollees have incomes below 138% FPL â that is, they would be enrolled in Medicaid if their states enacted the expansion.During OEP, buy zithromax online these 12 non-expansion states account for 81% of the enrollment gains in the 33 HealthCare.gov states, and about two-thirds of enrollment gains in all states. The table below also shows gains over a two-year period, encompassing the effects of the buy antibiotics zithromax.Total plan selections in non-expansion states**Dec.

15 open enrollment snapshots 2020-2022State202020212022Increase buy zithromax online 2021-2022% increase 2021-2022Increase 2020-2022% increase 2020-2022Alabama159,820168,399205,40737,00822.0%45,58728.5%Florida1,912,3942,115,4242,592,906477,48222.6%680,51235.6%Georgia464,041541,641653,999139,35827.1%189,95840.9%Kansas85,88088,497102,57314,07615.9%16,69319.4%Mississippi98,868110,519132,43221,91319.8%33,56433.9%North Carolina505,159536,270638,309102,03919.0%133,15026.4%South Carolina215,331230,033282,88252,84923.0%67,55131.4%South Dakota29,33031,28339,2928,00925.6%9,96234.0%Tennessee200,723211,474257,77846,30421.9%57,05528.4%Texas1,117,8821,284,5241,711,204426,68033.2%593,32253.1%Wisconsin196,594192,183205,99113,8087.2%9,3974.8%Wyoming24,66526,68433,0356,35123.8%8,37033.9%Non-expansion states5,010,6875,509,9316,855,8081,345,87724.4%1,845,12136.8%All HC.gov states7,533,9368,053,8429,724,2511,670,40920.7%2,190,31529.1%In the 39 states that have enacted the ACA Medicaid expansion (21 on HealthCare.gov and 18 running their own exchanges), far fewer enrollees are eligible for free Silver coverage. In expansion states, eligibility for marketplace subsidies begins at an income of 138% FPL, as people below buy zithromax online that threshold are eligible for Medicaid. Nevertheless, enrollment growth in non-expansion states during the current OEP is substantial, increasing by about 755,000 year-over-year, or 13%.The marketplace has been a zithromax âsafety netâThe marketplace has been a bulwark against uninsurance during the zithromax, among low-income people especially and in the non-expansion states in particular. As shown in the chart above, enrollment in these 11 buy zithromax online states increased by 1.8 million from Dec. 15, 2019 buy zithromax online to Dec.

15, 2021 â a 37% increase. For all states, the two-year increase is in the neighborhood of 25% and buy zithromax online will approach 3 million (from 11.4 million in OEP for 2020 to above 14 million when OEP for 2022 ends in January). Thatâs in addition to an increase of more than 12 million in Medicaid enrollment during the zithromax.While millions of Americans lost jobs when the zithromax struck, and millions fewer buy zithromax online are employed today than in February 2020, the uninsured rate did not increase during 2020, according to government surveys, and may even prove to have downticked during 2021 or 2022 when the data comes in.While the government has not yet published detailed statistics as to who has enrolled during the current OEP, they did do so in the final enrollment report for the emergency SEP. During the emergency SEP, out of 2.8 million new enrollees, 2.1 million were buy zithromax online in the 33 HealthCare.gov states. In those states, 41% of enrollees obtained Silver plans with the highest level of CSR, which means that they had incomes under 150% FPL (or received unemployment income) and so received free coverage in plans with an actuarial value of 94% â far above the norm for employer-sponsored plans.The median deductible obtained in HealthCare.gov states was $50, which makes sense, as 54% of enrollees obtained Silver plans with strong CSR, raising the planâs actuarial value to either 94% (at incomes up to 150% FPL) or to 87% (at incomes between 150% and 200% FPL).

Two-thirds of enrollees in HealthCare.gov states paid less than $50 per buy zithromax online month for coverage, and 37% obtained coverage for free.At higher incomes, as noted above, 400,000 enrollees who received subsidies in HealthCare.gov states would not have been subsidy-eligible before the ARP lifted the income cap on subsidies (previously 400% FPL). The same is also doubtless true for several hundred thousand enrollees in buy zithromax online state-based marketplaces. The SBEs account for a bit less than a third of all enrollment, but in those states, all of which have expanded Medicaid, the percentage of enrollees with income over 400% FPL is almost twice that of the HealthCare.gov states (12% versus 7% during the emergency SEP).ARP. A patch for the coverage buy zithromax online gap?. The strong enrollment growth in non-expansion states â an increase of 37% in two years â indicates that during the zithromax, some low-income people in those states found their way out of the coverage gap (caused by the lack of government help available to most adults with incomes below buy zithromax online 100% FPL).

In March 2020, the CARES Act (H.R.748) provided supplementary uninsurance income of $600 per week for up to four months to a wide range of people who had lost income during the zithromax, likely pushing many incomes over 100% FPL. In 2021, anyone who received any unemployment income qualified for free Silver coverage, and during the emergency SEP, 84,000 new enrollees took advantage of this provision buy zithromax online (along with 124,000 existing enrollees). That emergency provision is not in effect in 2022, however.Marketplace subsidies are based on an estimate of future income buy zithromax online. For low-income people in particular, who are often paid by the hour, work uncertain schedules, depend on tips, or are self-employed, income can be difficult to project. The desire to be insured during the zithromax may have spurred some applicants to make sure their estimates cleared the 100% buy zithromax online FPL threshold.

(Enrollment assisters and brokers can help applicants deploy every resource to meet this goal.)For OEP 2022, the Biden administration raised funding for nonprofit enrollment assistance buy zithromax online in HealthCare.gov states to record levels, enough to train and certify more than 1,500 enrollment navigators. This past spring, in compliance with a court order, the exchanges stopped requiring low-income applicants who estimated income over 100% FPL to provide documentation if the governmentâs âtrusted sourcesâ of information indicated an income below the threshold.Comparatively weak enrollment growth in Wisconsin may support the hypothesis that under pressure of the zithromax, some enrollees in other non-expansion states are climbing out of the coverage gap. Alone among buy zithromax online non-expansion states, Wisconsin has no coverage gap, as the state provides Medicaid to adults with incomes up to 100% FPL (rather than up to the 138% FPL threshold required by the ACA Medicaid expansion, which offers enhanced federal funding to participating states). In Wisconsin, buy zithromax online those whose income falls below the 100% FPL marketplace eligibility threshold have access to free coverage. Wisconsin is the only non-expansion state that did not experience double-digit enrollment growth in OEP 2022 or from 2020-2022.The future of increased subsidies is unclearThe American Rescue Plan was conceived as emergency zithromax relief, and its increased subsidies run only through 2022.

President Bidenâs Build Back Better bill, which passed in the House of Representatives but is currently stalled in the Senate, would extend the ARP subsidies through 2025 or possibly further.The large increase in buy zithromax online enrollment this year should add pressure on Congress to extend the improved subsidies into future years. Consumer response to the increased subsidies has proved immediate and buy zithromax online dramatic. The ARP subsidy boosts brought the Affordable Care Act much closer than previously to living up to the promise of âaffordableâ care expressed in its name. Going backwards on that promise should not be seen as a politically viable or ethical path.* * ** Another million people are enrolled in Basic Health Programs established under the ACA by Minnesota and New buy zithromax online York â low-cost, Medicaid-like programs for state residents with incomes under 200% FPL. Enrollment in these programs is on track buy zithromax online to increase by 13% this year, according to Charles Gabaâs estimate.** HealthCare.gov all-state totals are for the 33 states using the federal exchange this year.

Source. Charles Gaba, OE snapshots as of mid-December, buy zithromax online 2021-22, 2020-2021. See also CMS end-of-OEP snapshots for 2020, 2021, 2022 Andrew buy zithromax online Sprung is a freelance writer who blogs about politics and healthcare policy at xpostfactoid. His articles about the Affordable Care Act have appeared in publications including The American Prospect, Health Affairs, The Atlantic, and The New Republic. He is the winner of the National Institute of Health Care Managementâs 2016 buy zithromax online Digital Media Award.

He holds buy zithromax online a Ph.D. In English literature from the University of Rochester..

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Zithromax azithromycin 250mg dosage

How to cite this article:Singh http://wowsignal.co.uk/ OP zithromax azithromycin 250mg dosage. Comprehensive Mental Health Action Plan 2013â2030. We must rise zithromax azithromycin 250mg dosage to the challenge. Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development.

Further, in September 2021, the 74th World Health Assembly accepted the updates to the action plan, including updates to the target options for zithromax azithromycin 250mg dosage indicators and implementation. This is an opportunity for the psychiatric community to rise to the challenge and work towards the realization of these objectives and in turn to integrate psychiatry with the mainstream of medicine.The change in objectives and targets is summarized in [Table 1].Table 1. Comparison between Mental Health Action Plans 2013-20 and 2013-30Click here to viewAs it is obvious that there is an enormous opportunity zithromax azithromycin 250mg dosage for the psychiatric community to implement things that we always have been talking about like:Global target 2.2 â Target's doubling of community-based mental health facilities by 2030 in 80% of countries. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 â Integration of mental health care into primary healthcareGlobal target 3.2 â Reduction in suicide rate by one-third by 2030Global target 3.3 â Psychological care for disasterGlobal target 4.2 â Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing.

It is an opportunity for zithromax azithromycin 250mg dosage us to expand psychiatry by being involved in general medical care and reduce stigma. We must also utilize this opportunity to press for the greater representation of psychiatry in MBBS curriculum throughout the country and stop not till it gets a separate subject status in undergraduate medical studies.Now is the time for us to strive to achieve all the objectives which provide an opportunity to expand mental health care, reduce stigma, and translate all the talk of furthering the growth of mental health into action.[2] References 1.World Health Organization. Mental Health Action Plan 2013-2020 zithromax azithromycin 250mg dosage. Geneva.

World Health Organization zithromax azithromycin 250mg dosage. 2013. 2.World zithromax azithromycin 250mg dosage Health Organization. Comprehensive Mental Health Action Plan 2013-2030.

Geneva. World Health Organization. 2021. 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_811_21 Tables [Table 1]Abstract Background.

Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence. However, few studies have looked into it. No data are available regarding the variation of empathy with abstinence and motivation. Assessment based on cognitive and affective dimensions of empathy is needed.Aim.

This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls. Association of empathy with disease-specific variables, motivation, and abstinence was also done.Methods. This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol dependence and 60 healthy controls were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy.

The University of Rhode Island Change Assessment Scale was used to assess motivation. Other variables were assessed using a semi-structured pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA. Correlation was done using Pearson's correlation test.Results.

Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total empathy were higher in abstinent men. Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages. Empathy correlated negatively with number of relapses and positively with family history of addiction.Conclusions.

Empathy (both cognitive and affective) is significantly reduced in alcohol dependence. Higher empathy correlates with lesser relapses. Abstinence and progression in motivation cycle is associated with remission in empathic deficits.Keywords. Abstinence, alcohol, empathy, motivationHow to cite this article:Nachane HB, Nadadgalli GV, Umate MS.

Cognitive and affective empathy in men with alcohol dependence. Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2022 Aug 26];63:418-23. Available from. Https://www.indianjpsychiatry.org/text.asp?.

2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement â such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components â cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking. It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence. This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare.

The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.

Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019âAugust 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18â65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases. Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded.

As all the available cases were male, the study was restricted to males. Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department). Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence.

Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used. The scales were administered by a single rater in one sitting. The entire interview was completed in 20â30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale.

We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement). The subscales can be combined arithmetically (C + A + M â PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment.

Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY. IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables.

Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (Î·p2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant.

Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis. The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated.

Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families. None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1].

The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = â0.42, P = 0.001), followed by TE (r = â0.39, P = 0.002) and least with AE (r = â0.31, P = 0.016). This means that men with alcohol dependence who are more empathic tend to have lesser relapses.

Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mildâmoderate.Table 2. Relation of disease related variables with total empathy in casesClick here to viewMotivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09). About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent.

Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI]. 1.34â8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI. 2.63â14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09â5.77], P = 0.058).

This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71). Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11).

Difference was more significant for affective empathy (Î·p2 = 0.15) as compared to total empathy (Î·p2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2]. However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1.

Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2. Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation. Data expressed as mean (standard deviation)Click here to viewTable 4.

Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls. This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al.

Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called âcognitive-affective dissociation of empathyâ in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient â cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this. Empathy is a key factor in motivation to help others and oneself when in distress.

This suggests a role for it in motivation to quit and treatment seeking. Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes.

Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial. It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair http://www.ec-gustave-stoskopf-strasbourg.site.ac-strasbourg.fr/wp/?p=257 future problem solving in social situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics.

CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE. Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be âequally heritable.â However, more research in this area is needed.Our study was not without limitations.

Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed. We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation.

As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE. Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications. Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected.

Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management. Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution.

Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C. Alcohol dependence. A public health perspective.

Addiction 2002;97:633-45. 2.Willenbring ML. The past and future of research on treatment of alcohol dependence. Alcohol Res Health 2010;33:55-63.

3.DiClemente CC. Conceptual models and applied research. The ongoing contribution of the transtheoretical model. J Addict Nurs 2005;16:5-12.

4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I. Motivation for change and psychological distress in homeless substance abusers. J Subst Abuse Treat 2000;19:395-401. 5.Beckman LJ.

An attributional analysis of Alcoholics Anonymous. J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of âmotivation for changeâ in psychoanalytic treatment.

Int J Psychoanal 1972;53:51-9. 7.Miller WR. Motivation for treatment. A review with special emphasis on alcoholism.

Psychol Bull 1985;98:84-107. 8.Murphy PN, Bentall RP. Motivation to withdraw from heroin. A factor-analytic study.

Br J Addict 1992;87:245-50. 9.Maurage P, Grynberg D, NoÃ«l X, Joassin F, Philippot P, Hanak C, et al. Dissociation between affective and cognitive empathy in alcoholism. A specific deficit for the emotional dimension.

Alcohol Clin Exp Res 2011;35:1662-8. 10.de Vignemont F, Singer T. The empathic brain. How, when and why?.

Trends Cogn Sci 2006;10:435-41. 11.Reniers RL, Corcoran R, Drake R, Shryane NM, VÃ¶llm BA. The QCAE. A questionnaire of cognitive and affective empathy.

J Pers Assess 2011;93:84-95. 12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L. Empathy ability is impaired in alcohol-dependent patients. Am J Addict 2009;18:157-61.

13.McCown W. The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups. Br J Addict 1989;84:391-3. 14.Krebs D.

Empathy and auism. J Pers Soc Psychol 1975;32:1134-46. 15.Jolliffe D, Farrington DP. Development and validation of the basic empathy scale.

J Adolesc 2006;29:589-611. 16.McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy. Measurement and sample profiles.

Psychol Psychother 1983;20:368-75. 17.Ferrari V, Smeraldi E, Bottero G, Politi E. Addiction and empathy. A preliminary analysis.

Neurol Sci 2014;35:855-9. 18.Massey SH, Newmark RL, Wakschlag LS. Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda.

Drug Alcohol Rev 2018;37:316-32. 19.Uekermann J, Daum I. Social cognition in alcoholism. A link to prefrontal cortex dysfunction?.

Addiction 2008;103:726-35. 20.Uekermann J, Channon S, Winkel K, Schlebusch P, Daum I. Theory of mind, humour processing and executive functioning in alcoholism. Addiction 2007;102:232-40.

21.Gonzalez-Liencres C, Shamay-Tsoory SG, BrÃ¼ne M. Towards a neuroscience of empathy. Ontogeny, phylogeny, brain mechanisms, context and psychopathology. Neurosci Biobehav Rev 2013;37:1537-48.

22.Miller PA, Eisenberg N. The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44. 23.McCown W.

The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study. Br J Addict 1990;85:635-7. 24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al.

Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence. Alcohol Clin Exp Res 2007;31:1169-78. 25.Thoma P, Friedmann C, Suchan B. Empathy and social problem solving in alcohol dependence, mood disorders and selected personality disorders.

Neurosci Biobehav Rev 2013;37:448-70. 26.Marinkovic K, Oscar-Berman M, Urban T, O'Reilly CE, Howard JA, Sawyer K, et al. Alcoholism and dampened temporal limbic activation to emotional faces. Alcohol Clin Exp Res 2009;33:1880-92.

27.Smith A. Cognitive empathy and emotional empathy in human behavior and evolution. Psychol Rec 2006;56:3-21. 28.Decety J, Jackson PL.

A social-neuroscience perspective on empathy. Curr Dir Psychol Sci 2006;15:54-8. 29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism.

Alcohol Clin Exp Res 1988;12:471-80. 30.Moyers TB, Miller WR. Is low therapist empathy toxic?. Psychol Addict Behav 2013;27:878-84.

31.Heather N. Psychology and brief interventions. Br J Addict 1989;84:357-70. 32.Cook S, Heather N, McCambridge J.

Posttreatment motivation and alcohol treatment outcome 9 months later. Findings from structural equation modeling. J Consult Clin Psychol 2015;83:232-7. Correspondence Address:Hrishikesh Bipin Nachane63, Sharmishtha, Tarangan, Thane West, Thane - 400 606, Maharashtra IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1101_2 Figures [Figure 1], [Figure 2] Tables [Table 1], [Table 2], [Table 3], [Table 4].

How to http://www.ec-wintershouse.site.ac-strasbourg.fr/?page_id=279 cite buy zithromax online this article:Singh OP. Comprehensive Mental Health Action Plan 2013â2030. We must rise buy zithromax online to the challenge. Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development. Further, in September 2021, the 74th World Health Assembly accepted the updates to the action plan, buy zithromax online including updates to the target options for indicators and implementation.

This is an opportunity for the psychiatric community to rise to the challenge and work towards the realization of these objectives and in turn to integrate psychiatry with the mainstream of medicine.The change in objectives and targets is summarized in [Table 1].Table 1. Comparison between Mental Health Action Plans 2013-20 and 2013-30Click here to viewAs it buy zithromax online is obvious that there is an enormous opportunity for the psychiatric community to implement things that we always have been talking about like:Global target 2.2 â Target's doubling of community-based mental health facilities by 2030 in 80% of countries. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 â Integration of mental health care into primary healthcareGlobal target 3.2 â Reduction in suicide rate by one-third by 2030Global target 3.3 â Psychological care for disasterGlobal target 4.2 â Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing. It is an opportunity for us to expand buy zithromax online psychiatry by being involved in general medical care and reduce stigma. We must also utilize this opportunity to press for the greater representation of psychiatry in MBBS curriculum throughout the country and stop not till it gets a separate subject status in undergraduate medical studies.Now is the time for us to strive to achieve all the objectives which provide an opportunity to expand mental health care, reduce stigma, and translate all the talk of furthering the growth of mental health into action.[2] References 1.World Health Organization.

Mental Health buy zithromax online Action Plan 2013-2020. Geneva. World Health buy zithromax online Organization. 2013. 2.World Health Organization buy zithromax online.

Comprehensive Mental Health Action Plan 2013-2030. Geneva. World Health Organization. 2021. 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_811_21 Tables [Table 1]Abstract Background. Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence.

However, few studies have looked into it. No data are available regarding the variation of empathy with abstinence and motivation. Assessment based on cognitive and affective dimensions of empathy is needed.Aim. This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls. Association of empathy with disease-specific variables, motivation, and abstinence was also done.Methods.

This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol dependence and 60 healthy controls were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy. The University of Rhode Island Change Assessment Scale was used to assess motivation. Other variables were assessed using a semi-structured pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA.

Correlation was done using Pearson's correlation test.Results. Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total empathy were higher in abstinent men. Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages. Empathy correlated negatively with number of relapses and positively with family history of addiction.Conclusions.

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence. Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2022 Aug 26];63:418-23.

Available from. Https://www.indianjpsychiatry.org/text.asp?. 2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement â such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components â cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking. It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence.

This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare. The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.

Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department). Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence. Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used.

The scales were administered by a single rater in one sitting. The entire interview was completed in 20â30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale. We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement).

The subscales can be combined arithmetically (C + A + M â PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment. Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY. IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables.

The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated. Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families.

None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1]. The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = â0.42, P = 0.001), followed by TE (r = â0.39, P = 0.002) and least with AE (r = â0.31, P = 0.016).

This means that men with alcohol dependence who are more empathic tend to have lesser relapses. Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mildâmoderate.Table 2. Relation of disease related variables with total empathy in casesClick here to viewMotivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09). About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent.

Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11). Difference was more significant for affective empathy (Î·p2 = 0.15) as compared to total empathy (Î·p2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2].

However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1. Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2. Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation.

Data expressed as mean (standard deviation)Click here to viewTable 4. Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls. This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al.

Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes. Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial.

It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair future problem solving in social situations, thus impacting the prognosis of the illness.[25] Similarly, it also hampers treatment seeking in alcoholics. CE played a greater role in our sample as compared to AE, contrary to what most literature states.[26] This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also.[13],[23] Having a positive family history of mental illness/addictions was associated with higher CE and TE.

Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly.[21],[27] As AE did not show this relation, it appears CE and AE may not be âequally heritable.â However, more research in this area is needed.Our study was not without limitations. Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed. We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation.

Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution. Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C.

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32.Cook S, Heather N, McCambridge J. Posttreatment motivation and alcohol treatment outcome 9 months later. Findings from structural equation modeling. J Consult Clin Psychol 2015;83:232-7. Correspondence Address:Hrishikesh Bipin Nachane63, Sharmishtha, Tarangan, Thane West, Thane - 400 606, Maharashtra IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1101_2 Figures [Figure 1], [Figure 2] Tables [Table 1], [Table 2], [Table 3], [Table 4].