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SALT LAKE CITY, June 24, cheapest place to buy cialis 2021 cialis 10mg tablet cost /PRNewswire/ -- Health Catalyst, Inc. ("Health Catalyst," Nasdaq. HCAT), a leading provider of data and analytics technology and services to healthcare organizations, today announced that cialis 10mg tablet cost it has entered into a definitive agreement to acquire Twistle, Inc. ("Twistle"), an Albuquerque, New Mexico-based healthcare patient engagement SaaS technology company that automates patient-centered, HIPAA-compliant communication between care teams and patients to transform the patient experience, drive better care outcomes, and reduce healthcare costs. We anticipate that Twistle's leading clinical workflow and patient cialis 10mg tablet cost engagement platform, paired with the Health Catalyst population health offering, will enable a comprehensive go-to-market solution to address the population health needs of healthcare organizations, as well as Life Science organizations, around the globe.

Health Catalyst's cloud-based data platform, DOS™, will enhance Twistle's automation by enabling richer data-driven patient interaction. The Twistle technology also enables Health Catalyst's clinical, quality, and Life Sciences solutions, through established clinical pathways and patient communication channels."Twistle is a leading healthcare technology company committed to developing software that healthcare organizations and Life Science companies cialis 10mg tablet cost need to keep patients engaged in their healthcare," said Dan Burton, CEO of Health Catalyst. "Their efforts to improve patient outcomes and reduce the cost of care are deeply aligned with our mission to be the catalyst for massive, measurable, data-informed improvements. We're excited to welcome the Twistle team to Health Catalyst and look forward to working together to enable healthcare organizations to achieve the promise of population health." "Health Catalyst's acquisition of Twistle highlights our belief that the most promising technology in healthcare is combining cialis 10mg tablet cost AI and data with 'digital endpoints' for patient services to deliver value. Twistle creates endpoints that, in our experience, make it simple for us to interact asynchronously with patients in smarter ways, meeting them where they are digitally, and give our care teams the time to be even better at what they do best—delivering great care," said Aaron Martin, managing general partner of Providence Ventures and chief digital officer of Providence.

"Combined with Health Catalyst's data and analytics technology, we expect accelerated innovation in personalizing our outreach to patients," he added."The synergy between our cultures, values, and solutions will have a tremendous impact cialis 10mg tablet cost on the health and wellness of patients. Health Catalyst's patient insights can trigger personalized outreach, and the patient's unique profile will allow Twistle's communication pathways to adapt to their preferences and attributes in unprecedented ways. We are excited about the prospects of our joint solutions proactively cialis 10mg tablet cost engaging at-risk populations, advancing health equity, and improving patient activation in their care," said Kulmeet Singh, founder and CEO of Twistle. "We anticipate that care teams will realize even more efficiency gains as our automated outreach will be more intelligent and individualized, freeing their time to focus on patients that require intervention to stay on track with their medical plan of care."Health Catalyst expects to fund the transaction using a mix of stock and cash. The parties expect the transaction, which is subject to cialis 10mg tablet cost customary closing conditions, to close in early Q3 2021.

Further details regarding the acquisition will be reported on a Form 8-K filing that will be filed with the Securities and Exchange Commission today.About Health CatalystHealth Catalyst is a leading provider of data and analytics technology and services to healthcare organizations committed to being the catalyst for massive, measurable, data-informed healthcare improvement. Its customers leverage the cloud-based data platform—powered by data from more than 100 cialis 10mg tablet cost million patient records and encompassing trillions of facts—as well as its analytics software and professional services expertise to make data-informed decisions and realize measurable clinical, financial, and operational improvements. Health Catalyst envisions a future in which all healthcare decisions are data informed.About TwistleTwistle, a healthcare technology company founded in 2011, automates patient-centered, HIPAA-compliant communication between care teams and patients to transform the patient experience, drive better outcomes, and reduce costs. An automatic navigation (GPS) system for health, Twistle offers "turn-by-turn" guidance to patients as they navigate care journeys before, during, cialis 10mg tablet cost and after a care episode. Patients are engaged in their own care and follow best practices, communicate as needed with their care teams, and realize measurably better outcomes.

Twistle integrates sophisticated automation with multi-channel communication, engaging patients through secure text messaging, interactive voice cialis 10mg tablet cost response, patient portals, or the health system's digital applications.Cautionary Note Regarding Forward-Looking StatementsThis press release contains forward-looking statements relating to expectations, plans, and prospects including expectations relating to our ability to close, and the timing of the closing of, this transaction and the benefits that will be derived from this transaction. These forward-looking statements are based upon the current expectations and beliefs of Health Catalyst's management as of the date of this release, and are subject to certain risks and uncertainties that could cause actual results to differ materially from those described in the forward-looking statements including, without limitation, the risk of adverse and unpredictable macro-economic conditions and risks related to closing this transaction and integration of the companies. All forward-looking statements in this press release are based on information available to the Company as of the date hereof, and Health Catalyst disclaims any obligation to update these forward-looking statements.Media Contact:Amanda cialis 10mg tablet cost Hundtamanda.hundt@healthcatalyst.com575-491-0974 View original content to download multimedia:http://www.prnewswire.com/news-releases/health-catalyst-announces-agreement-to-acquire-twistle-301319757.htmlSOURCE Health CatalystSALT LAKE CITY, May 28, 2021 (GLOBE NEWSWIRE) -- Health Catalyst, Inc. ("Health Catalyst", Nasdaq. HCAT), a leading provider of data and analytics technology cialis 10mg tablet cost and services to healthcare organizations, today announced that Dan Burton, CEO, and Adam Brown, SVP of Investor Relations and FP&A, will participate in the 41st Annual William Blair Growth Stock Conference including a fireside chat on Wednesday, June 2, 2021 at 5:40 p.m.

ET. A webcast link will be available at https://ir.healthcatalyst.com/investor-relations cialis 10mg tablet cost. About Health Catalyst Health Catalyst is a leading provider of data and analytics technology and services to healthcare organizations committed to being the catalyst for massive, measurable, data-informed healthcare improvement. Its customers leverage the cloud-based data platform—powered by data from more than 100 million patient records and encompassing trillions of facts—as well as its analytics software and professional services expertise to make data-informed decisions and cialis 10mg tablet cost realize measurable clinical, financial, and operational improvements. Health Catalyst envisions a future in which all healthcare decisions are data informed.

Health Catalyst Investor cialis 10mg tablet cost Relations Contact. Adam BrownSenior Vice President, Investor Relations and FP&A+1 (855)-309-6800ir@healthcatalyst.com Health Catalyst Media Contact. Amanda Hundtamanda.hundt@healthcatalyst.com+1 (575) 491-0974.

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In this long term effects of cialis daily edition Open enrollment for 2021 health plans. Under 3 weeks remainingIf you or a loved one is in need of health insurance, or if you’re already enrolled in an individual-market (non-group) health plan, long term effects of cialis daily open enrollment is currently underway nationwide, and we’re past the half-way point. Enrollment started more than three weeks ago, and we now have under three weeks remaining.Our 2021 Open Enrollment Guide.

Everything you need to know to enroll in an affordable individual-market health plan.Open enrollment is an opportunity for people to newly enroll in health coverage – regardless of medical long term effects of cialis daily history or prior coverage – and it also allows people who are already enrolled to actively compare their available options for 2021 and select a different plan if it would serve them better.(Even if the current plan is still the best choice, this is always a better approach than simply letting the plan auto-renew without checking the other options.)Still have questions?. Read our extensive overview of open enrollment.Enrollments have surpassed 3 million nationwideAs of November 21, nearly 2.4 million people in 36 states had enrolled in coverage for 2021 through HealthCare.gov. A few of the state-run exchanges (used long term effects of cialis daily in Washington, DC, and the other 14 states) have also published enrollment updates.

According to Charles Gaba – who’s tracking enrollments nationwide – enrollment stood at more than 3 million as of November 25, including several hundred thousand enrollees in state-based exchanges whose coverage has been auto-renewed for 2021. (These individuals still have an opportunity to pick long term effects of cialis daily a different plan if they choose to do so). Gaba’s tally includes the states that use HealthCare.gov as well as the handful of state-run exchanges that have reported enrollment data, but most of the state-run exchanges have not yet made their enrollment data public.The daily enrollment pace via HealthCare.gov is higher than it was during the same time period last year, and that appears to be the case in the state-run exchanges as well.

But we aren’t yet seeing a significant surge in enrollment that might be expected given the job losses and associated coverage long term effects of cialis daily losses caused by the erectile dysfunction treatment cialis. However, enrollment in Medicaid has grown significantly this year, thanks to the ACA’s Medicaid expansion guidelines that allow people in most states to enroll in Medicaid if their income long term effects of cialis daily drops to under 138% of the poverty level, even if it was higher than that earlier in the year.Get Covered 2021 coalition seeks to slow the spread of erectile dysfunction treatment, get uninsured Americans enrolled in coverageGet Covered 2021 launched last week as a broad coalition of organizations with a two-part goal. Keeping Americans safe amid the erectile dysfunction treatment cialis, and spreading awareness about available health insurance options and the financial assistance that can make health coverage much more affordable than it would otherwise be.

€œGet Covered” is a long term effects of cialis daily reminder of the importance of wearing a mask to slow the spread of erectile dysfunction treatment, as well as the importance of having health insurance coverage.Get Covered 2021 is chaired by Carrie Banahan, who directs Kynect in Kentucky, Peter Lee, who directs Covered California, and Joshua Peck, co-founder of Get America Covered. The Get Covered 2021 coalition includes 15 state-run marketplaces and numerous national health care and consumer advocacy organizations.KFF finds 40% of Americans eligible for free 2021 health coverageA new analysis published this week by KFF finds that about 40% of uninsured Americans are eligible for free or nearly free health coverage for 2021. About a quarter of the uninsured are eligible for Medicaid, which is free in most states and has nominal premiums in a few states long term effects of cialis daily.

And another 16% are eligible for premium subsidies in the exchange that are substantial enough to allow them access to at least one private plan that would have no premiums at all.The free private plans are generally Bronze plans, although there are free Gold plans available in some areas. Selecting the free plans is not always the best option – some of these individuals will be better off with a Silver plan that includes cost-sharing reductions, even if they long term effects of cialis daily have to pay a higher monthly premium. But enrolling in free health coverage is certainly a far better option than remaining uninsured for the coming year.Maine healthcare organization to gather signatures for universal coverage initiative on 2022 ballotThree years ago, Maine made history when the state became the first to have Medicaid expansion approved via a ballot measure passed by voters.

Several other states long term effects of cialis daily have since followed suit. Now Maine Healthcare Action – a nonprofit focused on universal healthcare in Maine – has announced that it will begin gathering signatures in 2021 for another ballot measure, which would direct the legislature to create a universal health coverage system for the people of Maine by 2024.In order to get the measure on the 2022 ballot, long term effects of cialis daily 63,067 valid signatures are needed, although advocates are hoping to gather at least 80,000. They will have a year in which to get enough signatures to get the measure on the 2022 ballot.Healthcare sharing ministry fined $1 million by Washington, cease-and-desist order upheldFor well over a year, Washington Insurance Commissioner Mike Kreidler has been seeking a $1 million fine against healthcare sharing ministry Aliera Healthcare, Inc.

Kreidler had ordered the company to stop issuing memberships in Washington in the spring long term effects of cialis daily of 2019. (Other states have also stepped in to issue cease-and-desist orders for Aliera.)Aliera had appealed Kreidler’s cease-and-desist order, but it was upheld earlier this month. And this week, Aliera was ordered to pay the $1 million fine, although the company has 90 days to appeal that as well.Appellate court hears Oscar suit challenging Florida Blue exclusive broker requirementsLast fall, we told you about a lawsuit involving Oscar and Florida Blue, stemming from Florida Blue’s requirement that brokers who offer their products refrain from offering products from any other long term effects of cialis daily insurance company.

This is far from the norm. Brokers in most states are allowed – and generally encouraged – to become long term effects of cialis daily appointed with a variety of insurance companies, in order to offer their clients a broad selection of plans from which to choose.Oscar sued, alleging that Florida Blue’s exclusive broker requirement amounts to coercion and unfair market practices, but a judge sided with Florida Blue last September. Last week, the case was argued in front of a three-judge panel for the 11th Circuit Court of Appeals in Atlanta, but it’s not yet known when the judges will issue a ruling on the case.Brookings Institution paper analyzes strategies for reducing healthcare costsThe Brookings Institution’s Matt Fiedler has published a new paper that analyzes various options for reducing healthcare costs, including capping out-of-network prices, capping both in-network and out-of-network prices, and creating a public option.

Start with Fiedler’s Twitter thread about this, and then dig into the summaries and long term effects of cialis daily the paper itself.The short story?. It’s complicated and there are numerous pitfalls to avoid, but there are strategies that could successfully lower healthcare prices.Nevada health exchange director discusses increased enrollmentThis week, Megan Messerly of the Nevada Independent interviewed Heather Korbulic, the executive director of Nevada’s health insurance exchange (Nevada Health Link). Korbulic and Messerly cover a wide range of topics, including increased enrollment during special enrollment periods earlier this year, the increased plan availability during the current open enrollment period, and the potential impact of the pending long term effects of cialis daily Supreme Court ruling on the ACA.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 long term effects of cialis daily educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.Short-term health plans in Nebraska Short-term plans duration in NebraskaState statute (44-787) defines short-term health insurance in Nebraska as a policy lasting less than 12 months. Federal regulations that took effect in 2017 limited short-term plans to no more than three long term effects of cialis daily months, and prohibited their renewal.

But that changed under Trump administration’s rules that took effect in late 2018, allowing short-term plans to have initial terms up to 364 days (ie, the same as Nebraska’s existing law), and total duration, including renewals, of up to 36 months. Nebraska’s short-term long term effects of cialis daily health insurance regulationsThe current federal rules for short-term health plans were finalized in early August 2018. In late August, the Nebraska Department of Insurance noted that they had temporarily placed short-term insurer filings on hold, while they reviewed the new federal rule.In September 2018, the Nebraska Department of Insurance published a bulletin clarifying that while the state would allow short-term plans to follow the federal guidelines in terms of the length of the initial term and the total allowable duration of the plan, the state was also imposing a variety of other requirements for short-term plans.

Notably, short-term long term effects of cialis daily plans in Nebraska are required to:Provide a clear comparison of how the benefits in the short-term plan compare with the benefits required by an ACA-compliant individual market plan. The Department suggests that a comparison chart is a good way to go about this, and notes that examples of benefits that would need to be compared are “annual and lifetime limits, maternity coverage, mental health benefits, pre-existing condition restrictions, and pharmacy benefits.”Clearly state whether the plan can be renewed, how to go about renewing it, and how much it will cost to renew it.Clearly state any annual or lifetime limits that apply to the policy.Provide a 10-day free look period, as required under Neb. Rev.

Stat. § 44-710.18.Disclose the details of the plan’s provider network, including maintaining an up-to-date website that shows all of the currently contracted network providers.Nebraska Revised Statute 44-710.03 and 44-710.04 are applicable to short-term health plans.The Nebraska Department of Insurance had previously published a consumer alert in October 2016, warning residents to beware of “high-pressure telemarketers selling short-term health insurance products that are not compliant with the Affordable Care Act (ACA) despite their promises.”Short-term health insurance plans in Nebraska must be filed with the Nebraska Department of Insurance (via SERFF), must cover state-mandated benefits, and must comply with the state’s internal and external appeal requirements.Which insurers offer short-term plans in Nebraska?. Several insurance companies offer short-term health plans in Nebraska as of 2020.

These insurers have different underwriting rules, benefits, and policy durations. Carefully compare the details of any plans you’re considering, to make sure you understand the coverage and limitations. Who can buy short-term health insurance in Nebraska?.

Short-term health insurance in Nebraska can be purchased by applicants who can meet the underwriting guidelines the insurers use. In general, this means being under 65 years old (some insurers put the age limit at 64 years) and in fairly good health.Short-term health plans typically include blanket exclusions for pre-existing conditions, so they are not adequate for residents of the Cornhusker State who need certain medical care and seeking a short-term policy that will cover those needs.If you’re in need of health insurance coverage in Nebraska, first check to see if you’re eligible to enroll in an ACA-compliant major medical plan. These plans are available through the Nebraska exchange/marketplace or directly from an insurance company.

Open enrollment for ACA-compliant plans runs from November 1 – December 15 each year. Outside of that window, you may still be able to enroll, if you experience a qualifying event that triggers a special enrollment period. And if you have an eligible household income, you may be able to get a premium subsidy that would make your coverage much less costly than you might have expected — perhaps even less expensive than a short-term health plan.ACA-compliant plans are purchased on a month-to-month basis, so you can enroll in coverage even for only a few months until another policy takes effect.

So if you’ll soon be enrolled in Medicare or an employer’s plan, for example, you can sign up for an ACA-compliant plan during open enrollment or a special enrollment period, and then schedule it to end when your new coverage takes effect.When should I consider short-term health insurance in Nebraska ?. In your life there may be times when a short-term health insurance plan is the only realistic option, for example:If you missed open enrollment for ACA-compliant coverage and do not have a qualifying event that would trigger a special enrollment period.If you’re newly employed and have to wait up to three months before you can enroll in your employer’s health plan.If you’ll soon be enrolling in Medicare and have no other coverage options in the meantime.If you’ve already enrolled in an ACA-compliant plan but have to wait up to several weeks before the plan takes effect (ie, until January 1 if you’re enrolling during open enrollment, or until the first of the following month or the second following month if you’re enrolling during a special enrollment period).If you’re not eligible for Medicaid or a premium subsidy in the exchange for an ACA-compliant plan. People ineligible for premium subsidies include:Cornhuskers who earn over 400% of the poverty level.

(For 2021 coverage, that amounts to $51,040 for a single person. If your ACA-specific modified adjusted gross income is just a little above the subsidy-eligible threshold, there are steps you can take to reduce it).People stuck in the ACA’s family glitch.People who aren’t lawfully present in the US and thus are not eligible to enroll in a plan through the exchange (premium subsidies are only available in the exchange, and you have to be a lawfully present US resident in order to enroll through the exchange).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 healthinsurance.org.

Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

In this http://www.jamiegianna.com/2020/01/10/trends-strange-but-true/ edition Open enrollment for cialis 10mg tablet cost 2021 health plans. Under 3 weeks remainingIf you or a loved one is in need of health insurance, or if you’re already enrolled in cialis 10mg tablet cost an individual-market (non-group) health plan, open enrollment is currently underway nationwide, and we’re past the half-way point. Enrollment started more than three weeks ago, and we now have under three weeks remaining.Our 2021 Open Enrollment Guide. Everything you need to know to enroll in an affordable individual-market health plan.Open enrollment is an opportunity for people to newly enroll in health coverage – regardless of medical history or prior coverage – and it also allows people who are already cialis 10mg tablet cost enrolled to actively compare their available options for 2021 and select a different plan if it would serve them better.(Even if the current plan is still the best choice, this is always a better approach than simply letting the plan auto-renew without checking the other options.)Still have questions?.

Read our extensive overview of open enrollment.Enrollments have surpassed 3 million nationwideAs of November 21, nearly 2.4 million people in 36 states had enrolled in coverage for 2021 through HealthCare.gov. A few of cialis 10mg tablet cost the state-run exchanges (used in Washington, DC, and the other 14 states) have also published enrollment updates. According to Charles Gaba – who’s tracking enrollments nationwide – enrollment stood at more than 3 million as of November 25, including several hundred thousand enrollees in state-based exchanges whose coverage has been auto-renewed for 2021. (These individuals still have an cialis 10mg tablet cost opportunity to pick a different plan if they choose to do so).

Gaba’s tally includes the states that use HealthCare.gov as well as the handful of state-run exchanges that have reported enrollment data, but most of the state-run exchanges have not yet made their enrollment data public.The daily enrollment pace via HealthCare.gov is higher than it was during the same time period last year, and that appears to be the case in the state-run exchanges as well. But we aren’t yet seeing a significant surge in enrollment that might be expected given the job losses and associated coverage losses caused by the erectile dysfunction treatment cialis cialis 10mg tablet cost. However, enrollment in Medicaid has grown significantly this year, thanks to the ACA’s Medicaid expansion guidelines that allow people in most states to enroll in Medicaid if their income drops to under 138% of the poverty level, even if cialis 10mg tablet cost it was higher than that earlier in the year.Get Covered 2021 coalition seeks to slow the spread of erectile dysfunction treatment, get uninsured Americans enrolled in coverageGet Covered 2021 launched last week as a broad coalition of organizations with a two-part goal. Keeping Americans safe amid the erectile dysfunction treatment cialis, and spreading awareness about available health insurance options and the financial assistance that can make health coverage much more affordable than it would otherwise be.

€œGet Covered” is a reminder of the importance of wearing a mask to slow the spread of erectile dysfunction treatment, as well cialis 10mg tablet cost as the importance of having health insurance coverage.Get Covered 2021 is chaired by Carrie Banahan, who directs Kynect in Kentucky, Peter Lee, who directs Covered California, and Joshua Peck, co-founder of Get America Covered. The Get Covered 2021 coalition includes 15 state-run marketplaces and numerous national health care and consumer advocacy organizations.KFF finds 40% of Americans eligible for free 2021 health coverageA new analysis published this week by KFF finds that about 40% of uninsured Americans are eligible for free or nearly free health coverage for 2021. About a quarter of the uninsured are eligible for Medicaid, which is free in most states and has nominal cialis 10mg tablet cost premiums in a few states. And another 16% are eligible for premium subsidies in the exchange that are substantial enough to allow them access to at least one private plan that would have no premiums at all.The free private plans are generally Bronze plans, although there are free Gold plans available in some areas.

Selecting the free plans is not always the best option – some of these individuals cialis 10mg tablet cost will be better off with a Silver plan that includes cost-sharing reductions, even if they have to pay a higher monthly premium. But enrolling in free health coverage is certainly a far better option than remaining uninsured for the coming year.Maine healthcare organization to gather signatures for universal coverage initiative on 2022 ballotThree years ago, Maine made history when the state became the first to have Medicaid expansion approved via a ballot measure passed by voters. Several other states have since followed suit cialis 10mg tablet cost. Now Maine Healthcare Action – a nonprofit focused on universal healthcare in Maine – has announced that it will begin gathering signatures in 2021 for another ballot measure, which would direct the legislature to create a universal health coverage system for the people of Maine by 2024.In order to get the measure on the 2022 ballot, 63,067 cialis 10mg tablet cost valid signatures are needed, although advocates are hoping to gather at least 80,000.

They will have a year in which to get enough signatures to get the measure on the 2022 ballot.Healthcare sharing ministry fined $1 million by Washington, cease-and-desist order upheldFor well over a year, Washington Insurance Commissioner Mike Kreidler has been seeking a $1 million fine against healthcare sharing ministry Aliera Healthcare, Inc. Kreidler had ordered the company to stop cialis 10mg tablet cost issuing memberships in Washington in the spring of 2019. (Other states have also stepped in to issue cease-and-desist orders for Aliera.)Aliera had appealed Kreidler’s cease-and-desist order, but it was upheld earlier this month. And this week, Aliera was cialis 10mg tablet cost ordered to pay the $1 million fine, although the company has 90 days to appeal that as well.Appellate court hears Oscar suit challenging Florida Blue exclusive broker requirementsLast fall, we told you about a lawsuit involving Oscar and Florida Blue, stemming from Florida Blue’s requirement that brokers who offer their products refrain from offering products from any other insurance company.

This is far from the norm. Brokers in most states are allowed – and generally encouraged – to become appointed cialis 10mg tablet cost with a variety of insurance companies, in order to offer their clients a broad selection of plans from which to choose.Oscar sued, alleging that Florida Blue’s exclusive broker requirement amounts to coercion and unfair market practices, but a judge sided with Florida Blue last September. Last week, the case was argued in front of a three-judge panel for the 11th Circuit Court of Appeals in Atlanta, but it’s not yet known when the judges will issue a ruling on the case.Brookings Institution paper analyzes strategies for reducing healthcare costsThe Brookings Institution’s Matt Fiedler has published a new paper that analyzes various options for reducing healthcare costs, including capping out-of-network prices, capping both in-network and out-of-network prices, and creating a public option. Start with Fiedler’s Twitter thread about this, and then dig cialis 10mg tablet cost into the summaries and the paper itself.The short story?.

It’s complicated and there are numerous pitfalls to avoid, but there are strategies that could successfully lower healthcare prices.Nevada health exchange director discusses increased enrollmentThis week, Megan Messerly of the Nevada Independent interviewed Heather Korbulic, the executive director of Nevada’s health insurance exchange (Nevada Health Link). Korbulic and Messerly cover a wide range of topics, including increased enrollment during special enrollment periods earlier this year, the increased plan availability during the current open enrollment period, and the potential impact of https://bpkad.baliprov.go.id/dinas-kepemudaan-dan-olahraga-provinsi-bali/ the pending Supreme cialis 10mg tablet cost Court ruling on the ACA.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 cialis 10mg tablet cost Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.Short-term health plans in Nebraska Short-term plans duration in NebraskaState statute (44-787) defines short-term health insurance in Nebraska as a policy lasting less than 12 months.

Federal regulations that took effect in cialis 10mg tablet cost 2017 limited short-term plans to no more than three months, and prohibited their renewal. But that changed under Trump administration’s rules that took effect in late 2018, allowing short-term plans to have initial terms up to 364 days (ie, the same as Nebraska’s existing law), and total duration, including renewals, of up to 36 months. Nebraska’s short-term health insurance regulationsThe current federal rules for short-term health plans were cialis 10mg tablet cost finalized in early August 2018. In late August, the Nebraska Department of Insurance noted that they had temporarily placed short-term insurer filings on hold, while they reviewed the new federal rule.In September 2018, the Nebraska Department of Insurance published a bulletin clarifying that while the state would allow short-term plans to follow the federal guidelines in terms of the length of the initial term and the total allowable duration of the plan, the state was also imposing a variety of other requirements for short-term plans.

Notably, short-term plans in Nebraska are required to:Provide a clear comparison of how the benefits in the short-term plan compare with the benefits required by cialis 10mg tablet cost an ACA-compliant individual market plan. The Department suggests that a comparison chart is a good way to go about this, and notes that examples of benefits that would need to be compared are “annual and lifetime limits, maternity coverage, mental health benefits, pre-existing condition restrictions, and pharmacy benefits.”Clearly state whether the plan can be renewed, how to go about renewing it, and how much it will cost to renew it.Clearly state any annual or lifetime limits that apply to the policy.Provide a 10-day free look period, as required under Neb. Rev. Stat.

§ 44-710.18.Disclose the details of the plan’s provider network, including maintaining an up-to-date website that shows all of the currently contracted network providers.Nebraska Revised Statute 44-710.03 and 44-710.04 are applicable to short-term health plans.The Nebraska Department of Insurance had previously published a consumer alert in October 2016, warning residents to beware of “high-pressure telemarketers selling short-term health insurance products that are not compliant with the Affordable Care Act (ACA) despite their promises.”Short-term health insurance plans in Nebraska must be filed with the Nebraska Department of Insurance (via SERFF), must cover state-mandated benefits, and must comply with the state’s internal and external appeal requirements.Which insurers offer short-term plans in Nebraska?. Several insurance companies offer short-term health plans in Nebraska as of 2020. These insurers have different underwriting rules, benefits, and policy durations. Carefully compare the details of any plans you’re considering, to make sure you understand the coverage and limitations.

Who can buy short-term health insurance in Nebraska?. Short-term health insurance in Nebraska can be purchased by applicants who can meet the underwriting guidelines the insurers use. In general, this means being under 65 years old (some insurers put the age limit at 64 years) and in fairly good health.Short-term health plans typically include blanket exclusions for pre-existing conditions, so they are not adequate for residents of the Cornhusker State who need certain medical care and seeking a short-term policy that will cover those needs.If you’re in need of health insurance coverage in Nebraska, first check to see if you’re eligible to enroll in an ACA-compliant major medical plan. These plans are available through the Nebraska exchange/marketplace or directly from an insurance company.

Open enrollment for ACA-compliant plans runs from November 1 – December 15 each year. Outside of that window, you may still be able to enroll, if you experience a qualifying event that triggers a special enrollment period. And if you have an eligible household income, you may be able to get a premium subsidy that would make your coverage much less costly than you might have expected — perhaps even less expensive than a short-term health plan.ACA-compliant plans are purchased on a month-to-month basis, so you can enroll in coverage even for only a few months until another policy takes effect. So if you’ll soon be enrolled in Medicare or an employer’s plan, for example, you can sign up for an ACA-compliant plan during open enrollment or a special enrollment period, and then schedule it to end when your new coverage takes effect.When should I consider short-term health insurance in Nebraska ?.

In your life there may be times when a short-term health insurance plan is the only realistic option, for example:If you missed open enrollment for ACA-compliant coverage and do not have a qualifying event that would trigger a special enrollment period.If you’re newly employed and have to wait up to three months before you can enroll in your employer’s health plan.If you’ll soon be enrolling in Medicare and have no other coverage options in the meantime.If you’ve already enrolled in an ACA-compliant plan but have to wait up to several weeks before the plan takes effect (ie, until January 1 if you’re enrolling during open enrollment, or until the first of the following month or the second following month if you’re enrolling during a special enrollment period).If you’re not eligible for Medicaid or a premium subsidy in the exchange for an ACA-compliant plan. People ineligible for premium subsidies include:Cornhuskers who earn over 400% of the poverty level. (For 2021 coverage, that amounts to $51,040 for a single person. If your ACA-specific modified adjusted gross income is just a little above the subsidy-eligible threshold, there are steps you can take to reduce it).People stuck in the ACA’s family glitch.People who aren’t lawfully present in the US and thus are not eligible to enroll in a plan through the exchange (premium subsidies are only available in the exchange, and you have to be a lawfully present US resident in order to enroll through the exchange).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 healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts..

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The New cialis and propecia Year is a time of http://www.ec-st-georges-ii-haguenau.ac-strasbourg.fr/?p=359 change. Many embrace the season as an opportunity to create resolutions with great intentions to be healthier but are often disappointed weeks later when they are unable to sustain them. There are several reasons why resolutions prove cialis and propecia to be difficult to maintain, but with thought and planning, one can make lasting change for the better. A potential problem with a resolution is that it is too far outside a person’s norm. Not only is this type of cialis and propecia resolution hard to start, it’s difficult to sustain.

For example, if someone doesn’t exercise, setting a goal of exercising 60 minutes a day may be too far outside their normal exercise time of zero. The difficulty with this type of goal is self-image. If you don’t see yourself as cialis and propecia someone who exercises, it will be hard to sustain a goal of 60 minutes a day of exercise. The following https://cambridge-passport-photos.uk/product/family-special-offer-one-child-free-with-adult-cambridge-passport-photos/?attribute_family-members=One+Adult are some of the dos and don’ts of kicking off the new year with a commitment ofhealthier habits.Don’t.  Set a goal that is cialis and propecia too lofty to attain Choose something you are physically unable to do Expect change to be easy Proceed without a plan Give up too quickly.

Plans can be adjusted Do: Set a small goal to begin and build from there Work on self-image. Visualize yourself being a person who is successful at it Engage in deliberate self-talk like “I am choosing healthy behavior” and “I can do that” Work the resolution into your routine by connecting it to something you already do until itbecomes a daily, healthy habit Understand that even small increments of change are successes No matter what type of change one is working on, a better chance at sustainability includes starting small, visualization, recognition that it can be accomplished and connecting it to something already present in one’s routine. Small steps become habits cialis and propecia until the larger goal of living a healthier lifestyle is reached. €œFocus on one day at a time, one step at a time. Soon days turn into weeks and eachsmall step becomes a habit and helps cialis and propecia you reach your larger goal.

Remember doing something is better than doing nothing at all Michelle Lucchesi, M.A., L.L.P., is a therapist at MidMichigan Medical Center – Gratiot’s Psychiatric Partial Hospitalization Program. To learn more about the program, call (989) 466-3253, or visit www.midmichigan.org/pphp..

The New cialis 10mg tablet cost Year is a time of http://www.em-gliesberg-strasbourg.ac-strasbourg.fr/?p=214 change. Many embrace the season as an opportunity to create resolutions with great intentions to be healthier but are often disappointed weeks later when they are unable to sustain them. There are several reasons why resolutions prove to be difficult to maintain, but with thought and planning, one can cialis 10mg tablet cost make lasting change for the better. A potential problem with a resolution is that it is too far outside a person’s norm.

Not only is this type of resolution hard to start, cialis 10mg tablet cost it’s difficult to sustain. For example, if someone doesn’t exercise, setting a goal of exercising 60 minutes a day may be too far outside their normal exercise time of zero. The difficulty with this type of goal is self-image. If you don’t see yourself as someone who exercises, it will be hard to sustain a goal of 60 minutes a cialis 10mg tablet cost day of exercise.

The following are some of the dos and don’ts of kicking off online cialis prescription the new year with a commitment ofhealthier habits.Don’t.  Set a goal that is too lofty to attain Choose something cialis 10mg tablet cost you are physically unable to do Expect change to be easy Proceed without a plan Give up too quickly. Plans can be adjusted Do: Set a small goal to begin and build from there Work on self-image. Visualize yourself being a person who is successful at it Engage in deliberate self-talk like “I am choosing healthy behavior” and “I can do that” Work the resolution into your routine by connecting it to something you already do until itbecomes a daily, healthy habit Understand that even small increments of change are successes No matter what type of change one is working on, a better chance at sustainability includes starting small, visualization, recognition that it can be accomplished and connecting it to something already present in one’s routine.

Small steps become habits until cialis 10mg tablet cost the larger goal of living a healthier lifestyle is reached. €œFocus on one day at a time, one step at a time. Soon days turn into weeks and eachsmall step becomes a habit and helps you reach your cialis 10mg tablet cost larger goal. Remember doing something is better than doing nothing at all Michelle Lucchesi, M.A., L.L.P., is a therapist at MidMichigan Medical Center – Gratiot’s Psychiatric Partial Hospitalization Program.

To learn more about the program, call (989) 466-3253, or visit www.midmichigan.org/pphp..

Generic cialis 100mg

I don’t take sides on this nor am I being deliberately Machiavellian—conclusive findings feel reassuring, but shouldn’t one also generic cialis 100mg celebrate ‘negative’ studies with equal gusto. Studies showing no discernable difference have arguably more public health effect than positives—protection from potential harm further down the line that the ‘positive RCT’ hasn’t shown, economic investment in the (usually) more expensive new treatment to name but two. Whatever it says in the brochure, all that really matters is that the study has been done well and the results are generalisable. I rest my case.erectile dysfunction treatment and ageI think we can reasonably assert that generic cialis 100mg we ‘know a bit more about this cialis than we did a year ago’. However, there are many gaps, one of which is the only partly resolved issue of the relative susceptibility of children and adults.

The review by Petra Zimmerman and Nigel Curtis take answers to these questions to a new level. I can’t do this justice in a few lines, but the arguments for the vascular vulnerability in adults related to age and tobacco, immune function, interferon antibody prevalence, CMV seropositivity, T and B cell differences goes a generic cialis 100mg long way to explaining the now quite familiar epidemiology—essential reading. See page 429Paediatric emergency medicineAbuse and radiologyTwo linked studies by Kathryn Glenn and Helen Daley and colleagues examine adherence to guidance on CT brain imaging in infants with possible suspected physical abuse. The studies (both retrospective and based on routinely collected data) were concordant. Rates of detection of abnormal radiological signs with implications (clinical and legal) in the most susceptible group, young infants (0–6 months) those with head swelling, generic cialis 100mg bruising or neurological signs, were high (84% and 53% respectively).

The yield was much lower in older children with no risk signs. The advantages of CT are largely practical. Available 24/7 in most hospitals, quick generic cialis 100mg enough (minutes) to avoid sedation or anaesthesia. The disadvantages are well known—irradiation. Here, again the authors are generally agree.

Despite the low yield in older children that it might be reasonable to weigh up an immediate CT against an interval ‘Sievert-free’ MR 2–5 days later in older children without generic cialis 100mg any signs. See pages 461 and 456PreparationIn suspected paediatric sepsis, time to intervention linked to familiarity with the environment or priming (physical and collegiate) is a strong negative predictor of outcome. In theory, repetition of simulation should help but literature endorsing this is scarce. Ben McNaughten generic cialis 100mg and colleagues randomised a group of medical students and nurses to priming or not before a series of mannikin based scenarios. Though the primed group participants did not feel they were helped by their training, they performed significantly better in the key indices.

Time to IV access, administration of antibiotics and request for help from a senior. See page 467Status epilepticus generic cialis 100mg. Choice of second line drugA child/young adult arrives in PED in convulsive status epilepticus (CSE). She receives your departmental guideline benzodiazepine of choice, usually midazolam or lorazepam, but continues to fit. What next? generic cialis 100mg.

The last 3 years has seen a mushrooming of RCTs examining relative effects of levetiracetam (LVT) against phenytoin (Phe) and valproate the newer and older kids’ on the block. The individual results have been tantalisingly equivocal—differences in either direction, none alone conclusive and few of sufficient size to, alone, alter one’s own practice. Most of us (perhaps a little inflexibly) have taken a ‘better the devil generic cialis 100mg you know’ (whichever that is) stance. Colin Powell and colleagues systematic review and meta-analysis take us a step closer to an answer using primary outcomes of time to seizure cessation and adverse events as main measures. The whole group analysis showed a small advantage in CSE to LVT, but after a sensitivity analysis in which a study strongly favouring LVT was removed, differences were minimal.

Adverse events were fewer, generic cialis 100mg but not significantly so. It feels as if choice will come down, in part, to pragmatism. LVT is easier to draw up, doesn’t require a pump to infuse and is quicker. Is this sufficient or do we accept there may simply not be sufficient data to call this one? generic cialis 100mg. After all, life can’t always be dichotomised.

See page 470Wallace A, Sinclair O, Shepherd M, et al. Impact of oral corticosteroids generic cialis 100mg on respiratory outcomes in acute preschool wheeze. A randomised clinical trial. Arch Dis Child 2021:106:339–44.

Whatever it says in the brochure, all that really matters is that the study has been done well and the results cialis 10mg tablet cost are generalisable. I rest my case.erectile dysfunction treatment and ageI think we can reasonably assert that we ‘know a bit more about this cialis than we did a year ago’. However, there are many gaps, one of which is the only partly resolved issue of the relative susceptibility of children and adults.

The review by Petra Zimmerman and Nigel Curtis take answers to these questions to a new cialis 10mg tablet cost level. I can’t do this justice in a few lines, but the arguments for the vascular vulnerability in adults related to age and tobacco, immune function, interferon antibody prevalence, CMV seropositivity, T and B cell differences goes a long way to explaining the now quite familiar epidemiology—essential reading. See page 429Paediatric emergency medicineAbuse and radiologyTwo linked studies by Kathryn Glenn and Helen Daley and colleagues examine adherence to guidance on CT brain imaging in infants with possible suspected physical abuse.

The studies (both retrospective cialis 10mg tablet cost and based on routinely collected data) were concordant. Rates of detection of abnormal radiological signs with implications (clinical and legal) in the most susceptible group, young infants (0–6 months) those with head swelling, bruising or neurological signs, were high (84% and 53% respectively). The yield was much lower in older children with no risk signs.

The advantages of CT are largely practical cialis 10mg tablet cost. Available 24/7 in most hospitals, quick enough (minutes) to avoid sedation or anaesthesia. The disadvantages are well known—irradiation.

Here, again the authors are generally agree cialis 10mg tablet cost. Despite the low yield in older children that it might be reasonable to weigh up an immediate CT against an interval ‘Sievert-free’ MR 2–5 days later in older children without any signs. See pages 461 and 456PreparationIn suspected paediatric sepsis, time to intervention linked to familiarity with the environment or priming (physical and collegiate) is a strong negative predictor of outcome.

In theory, cialis 10mg tablet cost repetition of simulation should help but literature endorsing this is scarce. Ben McNaughten and colleagues randomised a group of medical students and nurses to priming or not before a series of mannikin based scenarios. Though the primed group participants did not feel they were helped by their training, they performed significantly better in the key indices.

Time to IV access, cialis 10mg tablet cost administration of antibiotics and request for help from a senior. See page 467Status epilepticus. Choice of second line drugA child/young adult arrives in PED in convulsive status epilepticus (CSE).

She receives your cialis 10mg tablet cost departmental guideline benzodiazepine of choice, usually midazolam or lorazepam, but continues to fit. What next?. The last 3 years has seen a mushrooming of RCTs examining relative effects of levetiracetam (LVT) against phenytoin (Phe) and valproate the newer and older kids’ on the block.

The individual results have been tantalisingly equivocal—differences in either direction, none alone conclusive and few of sufficient size cialis 10mg tablet cost to, alone, alter one’s own practice. Most of us (perhaps a little inflexibly) have taken a ‘better the devil you know’ (whichever that is) stance. Colin Powell and colleagues systematic review and meta-analysis take us a step closer to an answer using primary outcomes of time to seizure cessation and adverse events as main measures.

The whole group analysis showed a small advantage in CSE to LVT, but after a sensitivity analysis cialis 10mg tablet cost in which a study strongly favouring LVT was removed, differences were minimal. Adverse events were fewer, but not significantly so. It feels as if choice will come down, in part, to pragmatism.

LVT is easier to draw up, doesn’t require a pump to cialis 10mg tablet cost infuse and is quicker. Is this sufficient or do we accept there may simply not be sufficient data to call this one?. After all, life can’t always be dichotomised.

See page 470Wallace A, Sinclair O, Shepherd M, et cialis 10mg tablet cost al. Impact of oral corticosteroids on respiratory outcomes in acute preschool wheeze. A randomised clinical trial.

Arch Dis cialis 10mg tablet cost Child 2021:106:339–44. Doi. 10.1136/archdischild-2020-318971.The trial registration number was omitted during production of this article.

Cialis dosage 40mg

How to cite this article:Singh OP cialis dosage 40mg. Psychiatry research in India. Closing the research cialis dosage 40mg gap. Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science. Research in India in general and medical research in particular is always being criticized for lack of innovation and originality required for the cialis dosage 40mg delivery of health services suitable to Indian conditions.

Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or cialis dosage 40mg even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up to the mark and is not commensurate with the magnitude of the disease burden in India. According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases. The research cialis dosage 40mg conducted elsewhere may not be generalized to the Indian population owing to differences in biology, health-care systems, health practices, culture, and socioeconomic standards.

Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017–2018) of the Department of Health Research observed that “the biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.”[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research. While ICMR has a budget of 232 million dollars per year on health research, it is zilch in comparison to the annual budget expenditure of the National Institute cialis dosage 40mg of Health, USA, on biomedical research which is 32 billion dollars.The lacuna of quality research is not merely due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need cialis dosage 40mg our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical institutions.

The majority of these are done as thesis submission for fulfillment of the requirement of PG degree. From 2015 onward, publication of papers had been made an obligatory requirement for promotion of faculty to higher cialis dosage 40mg posts. Although it offered a unique opportunity for training of residents and stimulus for research, it failed to translate into production of quality research work as thesis was limited by time and it had to be done with other clinical and academic duties.While the top four medical colleges, namely AIIMS, New Delhi. PGIMER, Chandigarh. CMC, Vellore cialis dosage 40mg.

And SGIMS, Lucknow are among the top ten medical institutions in terms of publication in peer-reviewed journals, around 332 (57.3%) medical colleges have no research paper published in a decade between 2004 and 2014.[2]The research in psychiatry is realistically dominated by major research institutes which are doing commendable work, but there is a substantial lack of contemporary research originating from other centers. Dr. Chittaranjan Andrade (NIMHANS, Bengaluru) and Dr. K Jacob (CMC, Vellore) recently figured in the list of top 2% psychiatry researchers in the world from India in psychiatry.[3] Most of the research conducted in the field of psychiatry are limited to caregivers' burden, pathways of care, and other topics which can be done in limited resources available to psychiatry departments. While all these areas of work are important in providing proper care and treatment, there is overabundance of research in these areas.The Government of India is aggressively looking forward to enhancing the quality of research and is embarking on an ambitious project of purchasing all major journals and providing free access to universities across the country.

The India Genome Project started in January, 2020, is a good example of collaboration. While all these actions are laudable, a lot more needs to be done. Following are some measures which will reduce the gap:Research proposals at the level of protocol can be guided and mentored by institutes. Academic committees of different zones and journals can help in this endeavorBreaking the cubicles by establishing a collaboration between medical colleges and various institutes. While there is a lack of resources available in individual departments, there are universities and institutes with excellent infrastructure.

They are not aware of the requirements of the field of psychiatry and research questions. Creation of an alliance will enhance the quality of research work. Some of such institutes include Centre for Neuroscience, Indian Institute of Science, Bengaluru. CSIR-Institute of Genomics and Integrative Biology, New Delhi. And National Institute of Biomedical Genomics, KalyaniInitiation and establishment of interactive and stable relationships between basic scientists and clinical and technological experts will enhance the quality of research work and will lead to translation of basic biomedical research into real-time applications.

For example, work on artificial intelligence for mental health. Development of Apps by IITs. Genome India Project by the Government of India, genomic institutes, and social science and economic institutes working in the field of various aspects of mental healthUtilization of underutilized, well-equipped biotechnological labs of nonmedical colleges for furthering biomedical researchMedical colleges should collaborate with various universities which have labs providing testing facilities such as spectroscopy, fluoroscopy, gamma camera, scintigraphy, positron emission tomography, single photon emission computed tomography, and photoacoustic imagingCreating an interactive, interdepartmental, intradepartmental, and interinstitutional partnershipBy developing a healthy and ethical partnership with industries for research and development of new drugs and interventions.Walking the talk – the psychiatric fraternity needs to be proactive and rather than lamenting about the lack of resource, we should rise to the occasion and come out with innovative and original research proposals. With the implementation of collaborative approach, we can not only enhance and improve the quality of our research but to an extent also mitigate the effects of resource crunch and come up as a leader in the field of biomedical research. References 1.2.Nagoba B, Davane M.

Current status of medical research in India. Where are we?. Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J. Updated science-wide author databases of standardized citation indicators.

PLoS Biol 2020;18:e3000918. Correspondence Address:Dr. Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/indianjpsychiatry.indianjpsychiatry_1362_2Abstract Background. The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly.Aim. The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research.Materials and Methods. Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis. PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies.

Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme. Studies were summarized and reported descriptively.Results. Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas. Alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services.

Sociocultural factors play a major role in understanding and determining mental disorders.Conclusion. This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality. Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.Keywords. India, mental health, scheduled tribesHow to cite this article:Devarapalli S V, Kallakuri S, Salam A, Maulik PK.

Mental health research on scheduled tribes in India. Indian J Psychiatry 2020;62:617-30 Introduction Mental health is a highly neglected area particularly in low and middle-income countries (LMIC). Data from community-based studies showed that about 10% of people suffer from common mental disorders (CMDs) such as depression, anxiety, and somatic complaints.[1] A systematic review of epidemiological studies between 1960 and 2009 in India reported that about 20% of the adult population in the community are affected by psychiatric disorders in the community, ranging from 9.5 to 103/1000 population, with differences in case definitions, and methods of data collection, accounting for most of the variation in estimates.[2]The scheduled tribes (ST) population is a marginalized community and live in relative social isolation with poorer health indices compared to similar nontribal populations.[3] There are an estimated 90 million STs or Adivasis in India.[4] They constitute 8.6% of the total Indian population. The distribution varies across the states and union territories of India, with the highest percentage in Lakshadweep (94.8%) followed by Mizoram (94.4%). In northeastern states, they constitute 65% or more of the total population.[5] The ST communities are identified as culturally or ethnographically unique by the Indian Constitution.

They are populations with poorer health indicators and fewer health-care facilities compared to non-ST rural populations, even when within the same state, and often live in demarcated geographical areas known as ST areas.[4]As per the National Family Health Survey, 2015–2016, the health indicators such as infant mortality rate (IMR) is 44.4, under five mortality rate (U5MR) is 57.2, and anemia in women is 59.8 for STs – one of the most disadvantaged socioeconomic groups in India, which are worse compared to other populations where IMR is 40.7, U5MR is 49.7, and anemia in women among others is 53.0 in the same areas.[6] Little research is available on the health of ST population. Tribal mental health is an ignored and neglected area in the field of health-care services. Further, little data are available about the burden of mental disorders among the tribal communities. Health research on tribal populations is poor, globally.[7] Irrespective of the data available, it is clear that they have worse health indicators and less access to health facilities.[8] Even less is known about the burden of mental disorders in ST population. It is also found that the traditional livelihood system of the STs came into conflict with the forces of modernization, resulting not only in the loss of customary rights over the livelihood resources but also in subordination and further, developing low self-esteem, causing great psychological stress.[4] This community has poor health infrastructure and even less mental health resources, and the situation is worse when compared to other communities living in similar areas.[9],[10]Only 15%–25% of those affected with mental disorders in LMICs receive any treatment for their mental illness,[11] resulting in a large “treatment gap.”[12] Treatment gaps are more in rural populations,[13] especially in ST communities in India, which have particularly poor infrastructure and resources for health-care delivery in general, and almost no capacity for providing mental health care.[14]The aim of this systematic review was to explore the extent and nature of mental health research on ST population in India and to identify gaps and inform future research.

Materials and Methods Search strategyWe searched major databases (PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar) and made hand searches from January 1980 to December 2018 to identify relevant literature. Hand search refers to searching through medical journals which are not indexed in the major electronic databases such as Embase, for instance, searching for Indian journals in IndMed database as most of these journals are not available in major databases. Physical search refers to searching the journals that were not available online or were not available online during the study years. We used relevant Medical Subject Heading and key terms in our search strategy, as follows. €œMental health,” “Mental disorders,” “Mental illness,” “Psychiatry,” “Scheduled Tribe” OR “Tribe” OR “Tribal Population” OR “Indigenous population,” “India,” “Psych*” (Psychiatric, psychological, psychosis).Inclusion criteriaStudies published between January 1980 and December 2018 were included.

Studies on mental disorders were included only when they focused on ST population. Both qualitative and quantitative studies on mental disorders of ST population only were included in the analysis.Exclusion criteriaStudies without any primary data and which are merely overviews and commentaries and those not focused on ST population were excluded from the analysis.Data management and analysisTwo researchers (SD and SK) initially screened the title and abstract of each record to identify relevant papers and subsequently screened full text of those relevant papers. Any disagreements between the researchers were resolved by discussion or by consulting with an adjudicator (PKM). From each study, data were extracted on objectives, study design, study population, study duration, interventions (if applicable), outcomes, and results. Quality of the included studies was assessed, independently by three researchers (SD, SK, and AS), using Critical Appraisal Checklist developed by Critical Appraisal Skills Programme (CASP).[15] After a thorough qualitative assessment, all quantitative data were generated and tabulated.

A narrative description of the studies is provided in [Table 1] using some broad categories. Results Search resultsOur search retrieved 2306 records (which included hand-searched articles), of which after removing duplicates, title and abstracts of 2278 records were screened. Of these, 178 studies were deemed as potentially relevant and were reviewed in detail. Finally, we excluded 146 irrelevant studies and 32 studies were included in the review [Figure 1].Quality of the included studiesSummary of quality assessment of the included studies is reported in [Table 2]. Overall, nine studies were of poor quality, twenty were of moderate quality, and three studies were of high quality.

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

And methods used were not sufficiently described to repeat them. Studies under the moderate quality did not have a representative sample. Non-responders categories was not addressed. Risk factors were not measured correctly. And methods used were not sufficiently described to allow the study to be replicated by other researchers.The included studies covered three broad categories.

Alcohol and substance use disorders, CMD (depression, anxiety, stress, and suicide risk), socio-cultural aspects, and access to mental health services.Alcohol and substance use disordersFive studies reviewed the consumption of alcohol and opioid. In an ethnographic study conducted in three western districts in Rajasthan, 200 opium users were interviewed. Opium consumption was common among both younger and older males during nonharvest seasons. The common causes for using opium were relief of anxiety related to crop failure due to drought, stress, to get a high, be part of peers, and for increased sexual performance.[16]In a study conducted in Arunachal Pradesh involving a population of more than 5000 individuals, alcohol use was present in 30% and opium use in about 5% adults.[17] Contrary to that study, in Rajasthan, the prevalence of opium use was more in women and socioeconomic factors such as occupation, education, and marital status were associated with opium use.[16] The prevalence of opium use increased with age in both sexes, decreased with increasing education level, and increased with employment. It was observed that wages were used to buy opium.

In the entire region of Chamlang district of Arunachal Pradesh, female substance users were almost half of the males among ST population.[17] Types of substance used were tobacco, alcohol, and opium. Among tobacco users, oral tobacco use was higher than smoking. The prevalence of tobacco use was higher among males, but the prevalence of alcohol use was higher in females, probably due to increased access to homemade rice brew generally prepared by women. This study is unique in terms of finding a strong association with religion and culture with substance use.[18]Alcohol consumption among Paniyas of Wayanad district in Kerala is perceived as a male activity, with many younger people consuming it than earlier. A study concluded that alcohol consumption among them was less of a “choice” than a result of their conditions operating through different mechanisms.

In the past, drinking was traditionally common among elderly males, however the consumption pattern has changed as a significant number of younger men are now drinking. Drinking was clustered within families as fathers and sons drank together. Alcohol is easily accessible as government itself provides opportunities. Some employers would provide alcohol as an incentive to attract Paniya men to work for them.[19]In a study from Jharkhand, several ST community members cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol. Societal acceptance of drinking alcohol and peer pressure, as well as high emotional problems, appeared to be the major etiology leading to higher prevalence of substance dependence in tribal communities.[20] Another study found high life time alcohol use prevalence, and the reasons mentioned were increased poverty, illiteracy, increased stress, and peer pressure.[21] A household survey from Chamlang district of Arunachal Pradesh revealed that there was a strong association between opium use and age, occupation, marital status, religion, and ethnicity among both the sexes of STs, particularly among Singhpho and Khamti.[15] The average age of onset of tobacco use was found to be 16.4 years for smoked and 17.5 years for smokeless forms in one study.[22]Common mental disorders and socio-cultural aspectsSuicide was more common among Idu Mishmi in Roing and Anini districts of Arunachal Pradesh state (14.2%) compared to the urban population in general (0.4%–4.2%).

Suicides were associated with depression, anxiety, alcoholism, and eating disorders. Of all the factors, depression was significantly high in people who attempted suicide.[24] About 5% out of 5007 people from thirty villages comprising ST suffered from CMDs in a study from West Godavari district in rural Andhra Pradesh. CMDs were defined as moderate/severe depression and/or anxiety, stress, and increased suicidal risk. Women had a higher prevalence of depression, but this may be due to the cultural norms, as men are less likely to express symptoms of depression or anxiety, which leads to underreporting. Marital status, education, and age were prominently associated with CMD.[14] In another study, gender, illiteracy, infant mortality in the household, having <3 adults living in the household, large family size with >four children, morbidity, and having two or more life events in the last year were associated with increased prevalence of CMD.[24] Urban and rural ST from the same community of Bhutias of Sikkim were examined, and it was found that the urban population experienced higher perceived stress compared to their rural counterparts.[25] Age, current use of alcohol, poor educational status, marital status, social groups, and comorbidities were the main determinants of tobacco use and nicotine dependence in a study from the Andaman and Nicobar Islands.[22] A study conducted among adolescents in the schools of rural areas of Ranchi district in Jharkhand revealed that about 5% children from the ST communities had emotional symptoms, 9.6% children had conduct problems, 4.2% had hyperactivity, and 1.4% had significant peer problems.[27] A study conducted among the female school teachers in Jharkhand examined the effects of stress, marital status, and ethnicity upon the mental health of school teachers.

The study found that among the three factors namely stress, marital status, and ethnicity, ethnicity was found to affect mental health of the school teachers most. It found a positive relationship between mental health and socioeconomic status, with an inverse relationship showing that as income increased, the prevalence of depression decreased.[28] A study among Ao-Nagas in Nagaland found that 74.6% of the population attributed mental health problems to psycho-social factors and a considerable proportion chose a psychiatrist or psychologist to overcome the problem. However, 15.4% attributed mental disorders to evil spirits. About 47% preferred to seek treatment with a psychiatrist and 25% preferred prayers. Nearly 10.6% wanted to seek the help of both the psychiatrist and prayer group and 4.4% preferred traditional healers.[28],[29] The prevalence of Down syndrome among the ST in Chikhalia in Barwani district of Madhya Pradesh was higher than that reported in overall India.

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

The study included 238 adults suffering from CMD. During the intervention period, 12.6% visited the primary health-care doctors compared to only 0.8% who had sought any care for their mental disorders prior to the intervention. The study also found a significant reduction in the depression and anxiety scores at the end of intervention and improvements in stigma perceptions related to mental health.[14] A study in Gudalur and Pandalur Taluks of Nilgiri district from Tamil Nadu used low cost task shifting by providing community education and identifying and referring individuals with psychiatric problems as effective strategies for treating mental disorders in ST communities. Through the program, the health workers established a network within the village, which in turn helped the patients to interact with them freely. Consenting patients volunteered at the educational sessions to discuss their experience about the effectiveness of their treatment.

Community awareness programs altered knowledge and attitudes toward mental illness in the community.[33] A study in Nilgiri district, Tamil Nadu, found that the community had been taking responsibility of the patients with the system by providing treatment closer to home without people having to travel long distances to access care. Expenses were reduced by subsidizing the costs of medicine and ensuring free hospital admissions and referrals to the people.[34] A study on the impact of gender, socioeconomic status, and age on mental health of female factory workers in Jharkhand found that the ST women were more likely to face stress and hardship in life due to diverse economic and household responsibilities, which, in turn, severely affected their mental health.[35] Prevalence of mental health morbidity in a study from the Sunderbans delta found a positive relation with psycho-social stressors and poor quality of life. The health system in that remote area was largely managed by “quack doctors” and faith healers. Poverty, illiteracy, and detachment from the larger community helped reinforce superstitious beliefs and made them seek both mental and physical health care from faith healers.[36] In a study among students, it was found that children had difficulties in adjusting to both ethnic and mainstream culture.[27] Low family income, inadequate housing, poor sanitation, and unhealthy and unhygienic living conditions were some environmental factors contributing to poor physical and mental growth of children. It was observed that children who did not have such risk factors maintained more intimate relations with the family members.

Children belonging to the disadvantaged environment expressed their verbal, emotional need, blame, and harm avoidances more freely than their counterparts belonging to less disadvantaged backgrounds. Although disadvantaged children had poor interfamilial interaction, they had better relations with the members outside family, such as peers, friends, and neighbors.[37] Another study in Jharkhand found that epilepsy was higher among ST patients compared to non-ST patients.[31] Most patients among the ST are irregular and dropout rates are higher among them than the non-ST patients. Urbanization per se exerted no adverse influence on the mental health of a tribal community, provided it allowed preservation of ethnic and cultural practices. Women in the ST communities were less vulnerable to mental illness than men. This might be a reflection of their increased responsibilities and enhanced gender roles that are characteristic of women in many ST communities.[38] Data obtained using culturally relevant scales revealed that relocated Sahariya suffer a lot of mental health problems, which are partially explained by livelihood and poverty-related factors.

The loss of homes and displacement compromise mental health, especially the positive emotional well-being related to happiness, life satisfaction, optimism for future, and spiritual contentment. These are often not overcome even with good relocation programs focused on material compensation and livelihood re-establishment.[39] Discussion This systematic review is to our knowledge the first on mental health of ST population in India. Few studies on the mental health of ST were available. All attempts including hand searching were made to recover both published peer-reviewed papers and reports available on the website. Though we searched gray literature, it may be possible that it does not capture all articles.

Given the heterogeneity of the papers, it was not possible to do a meta-analysis, so a narrative review was done.The quality of the studies was assessed by CASP. The assessment shows that the research conducted on mental health of STs needs to be carried out more effectively. The above mentioned gaps need to be filled in future research by considering the resources effectively while conducting the studies. Mental and substance use disorders contribute majorly to the health disparities. To address this, one needs to deliver evidence-based treatments, but it is important to understand how far these interventions for the indigenous populations can incorporate cultural practices, which are essential for the development of mental health services.[30] Evidence has shown a disproportionate burden of suicide among indigenous populations in national and regional studies, and a global and systematic investigation of this topic has not been undertaken to date.

Previous reviews of suicide epidemiology among indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth, high-income countries, or regions such as Oceania or the Arctic.[46] The only studies in our review which provided data on suicide were in Idu Mishmi, an isolated tribal population of North-East India, and tribal communities from Sunderban delta.[24],[37] Some reasons for suicide in these populations could be the poor identification of existing mental disorders, increased alcohol use, extreme poverty leading to increased debt and hopelessness, and lack of stable employment opportunities.[24],[37] The traditional consumption pattern of alcohol has changed due to the reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement.[19],[20]Faith healers play a dominant role in treating mental disorders. There is less awareness about mental health and available mental health services and even if such knowledge is available, access is limited due to remoteness of many of these villages, and often it involves high out-of-pocket expenditure.[35] Practitioners of modern medicine can play a vital role in not only increasing awareness about mental health in the community, but also engaging with faith healers and traditional medicine practitioners to help increase their capacity to identify and manage CMDs that do not need medications and can be managed through simple “talk therapy.” Knowledge on symptoms of severe mental disorders can also help such faith healers and traditional medicine practitioners to refer cases to primary care doctors or mental health professionals.Remote settlements make it difficult for ST communities to seek mental health care. Access needs to be increased by using solutions that use training of primary health workers and nonphysician health workers, task sharing, and technology-enabled clinical decision support tools.[3] The SMART Mental Health project was delivered in the tribal areas of Andhra Pradesh using those principles and was found to be beneficial by all stakeholders.[14]Given the lack of knowledge about mental health problems among these communities, the government and nongovernmental organizations should collect and disseminate data on mental disorders among the ST communities. More research funding needs to be provided and key stakeholders should be involved in creating awareness both in the community and among policy makers to develop more projects for ST communities around mental health. Two recent meetings on tribal mental health – Round Table Meeting on Mental Health of ST Populations organized by the George Institute for Global Health, India, in 2017,[51] and the First National Conference on Tribal Mental Health organized by the Indian Psychiatric Society in Bhubaneswar in 2018 – have identified some key areas of research priority for mental health in ST communities.

A national-level policy on mental health of tribal communities or population is advocated which should be developed in consultation with key stakeholders. The Indian Psychiatric Society can play a role in coordinating research activities with support of the government which can ensure regular monitoring and dissemination of the research impact to the tribal communities. There is a need to understand how mental health symptoms are perceived in different ST communities and investigate the healing practices associated with distress/disaster/death/loss/disease. This could be done in the form of cross-sectional or cohort studies to generate proper evidence which could also include the information on prevalence, mental health morbidity, and any specific patterns associated with a specific disorder. Future research should estimate the prevalence of mental disorders in different age groups and gender, risk factors, and the influence of modernization.

Studies should develop a theoretical model to understand mental disorders and promote positive mental health within ST communities. Studies should also look at different ST communities as cultural differences exist across them, and there are also differences in socioeconomic status which impact on ability to access care.Research has shown that the impact and the benefits are amplified when research is driven by priorities that are identified by indigenous communities and involve their active participation. Their knowledge and perspectives are incorporated in processes and findings. Reporting of findings is meaningful to the communities. And indigenous groups and other key stakeholders are engaged from the outset.[47] Future research in India on ST communities should also adhere to these broad principles to ensure relevant and beneficial research, which have direct impact on the mental health of the ST communities.There is also a need to update literature related to mental health of ST population continuously.

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

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Health care delivery model in epilepsy to reduce treatment gap. WHO study from a rural tribal population of India. Epilepsy Res Elsevier 2009;84:146-52. 32.Prabhakar H, Manoharan R. The Tribal Health Initiative model for healthcare delivery.

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39.Ozer S, Acculturation, adaptation, and mental health among Ladakhi College Students a mixed methods study of an indigenous population. J Cross Cultl Psychol 2015;46:435-53. 40.Giri DK, Chaudhary S, Govinda M, Banerjee A, Mahto AK, Chakravorty PK. Utilization of psychiatric services by tribal population of Jharkhand through community outreach programme of RINPAS. Eastern J Psychiatry 2007;10:25-9.

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Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].

How to cialis 10mg tablet cost cite this article:Singh OP. Psychiatry research in India. Closing the cialis 10mg tablet cost research gap. Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science. Research in cialis 10mg tablet cost India in general and medical research in particular is always being criticized for lack of innovation and originality required for the delivery of health services suitable to Indian conditions.

Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up to the mark and cialis 10mg tablet cost is not commensurate with the magnitude of the disease burden in India. According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases. The research conducted elsewhere cialis 10mg tablet cost may not be generalized to the Indian population owing to differences in biology, health-care systems, health practices, culture, and socioeconomic standards.

Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017–2018) of the Department of Health Research observed that “the biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.”[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research. While ICMR has a budget of 232 million dollars per year on health research, it is zilch in comparison to the annual budget expenditure of the National Institute of Health, USA, on cialis 10mg tablet cost biomedical research which is 32 billion dollars.The lacuna of quality research is not merely due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research cialis 10mg tablet cost in India are conducted in medical institutions.

The majority of these are done as thesis submission for fulfillment of the requirement of PG degree. From 2015 onward, publication of papers cialis 10mg tablet cost had been made an obligatory requirement for promotion of faculty to higher posts. Although it offered a unique opportunity for training of residents and stimulus for research, it failed to translate into production of quality research work as thesis was limited by time and it had to be done with other clinical and academic duties.While the top four medical colleges, namely AIIMS, New Delhi. PGIMER, Chandigarh. CMC, Vellore cialis 10mg tablet cost.

And SGIMS, Lucknow are among the top ten medical institutions in terms of publication in peer-reviewed journals, around 332 (57.3%) medical colleges have no research paper published in a decade between 2004 and 2014.[2]The research in psychiatry is realistically dominated by major research institutes which are doing commendable work, but there is a substantial lack of contemporary research originating from other centers. Dr. Chittaranjan Andrade (NIMHANS, Bengaluru) and Dr. K Jacob (CMC, Vellore) recently figured in the list of top 2% psychiatry researchers in the world from India in psychiatry.[3] Most of the research conducted in the field of psychiatry are limited to caregivers' burden, pathways of care, and other topics which can be done in limited resources available to psychiatry departments. While all these areas of work are important in providing proper care and treatment, there is overabundance of research in these areas.The Government of India is aggressively looking forward to enhancing the quality of research and is embarking on an ambitious project of purchasing all major journals and providing free access to universities across the country.

The India Genome Project started in January, 2020, is a good example of collaboration. While all these actions are laudable, a lot more needs to be done. Following are some measures which will reduce the gap:Research proposals at the level of protocol can be guided and mentored by institutes. Academic committees of different zones and journals can help in this endeavorBreaking the cubicles by establishing a collaboration between medical colleges and various institutes. While there is a lack of resources available in individual departments, there are universities and institutes with excellent infrastructure.

They are not aware of the requirements of the field of psychiatry and research questions. Creation of an alliance will enhance the quality of research work. Some of such institutes include Centre for Neuroscience, Indian Institute of Science, Bengaluru. CSIR-Institute of Genomics and Integrative Biology, New Delhi. And National Institute of Biomedical Genomics, KalyaniInitiation and establishment of interactive and stable relationships between basic scientists and clinical and technological experts will enhance the quality of research work and will lead to translation of basic biomedical research into real-time applications.

For example, work on artificial intelligence for mental health. Development of Apps by IITs. Genome India Project by the Government of India, genomic institutes, and social science and economic institutes working in the field of various aspects of mental healthUtilization of underutilized, well-equipped biotechnological labs of nonmedical colleges for furthering biomedical researchMedical colleges should collaborate with various universities which have labs providing testing facilities such as spectroscopy, fluoroscopy, gamma camera, scintigraphy, positron emission tomography, single photon emission computed tomography, and photoacoustic imagingCreating an interactive, interdepartmental, intradepartmental, and interinstitutional partnershipBy developing a healthy and ethical partnership with industries for research and development of new drugs and interventions.Walking the talk – the psychiatric fraternity needs to be proactive and rather than lamenting about the lack of resource, we should rise to the occasion and come out with innovative and original research proposals. With the implementation of collaborative approach, we can not only enhance and improve the quality of our research but to an extent also mitigate the effects of resource crunch and come up as a leader in the field of biomedical research. References 1.2.Nagoba B, Davane M.

Current status of medical research in India. Where are we?. Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J. Updated science-wide author databases of standardized citation indicators.

PLoS Biol 2020;18:e3000918. Correspondence Address:Dr. Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/indianjpsychiatry.indianjpsychiatry_1362_2Abstract Background. The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly.Aim. The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research.Materials and Methods. Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis. PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies.

Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme. Studies were summarized and reported descriptively.Results. Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas. Alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services.

Sociocultural factors play a major role in understanding and determining mental disorders.Conclusion. This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality. Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.Keywords. India, mental health, scheduled tribesHow to cite this article:Devarapalli S V, Kallakuri S, Salam A, Maulik PK.

Mental health research on scheduled tribes in India. Indian J Psychiatry 2020;62:617-30 Introduction Mental health is a highly neglected area particularly in low and middle-income countries (LMIC). Data from community-based studies showed that about 10% of people suffer from common mental disorders (CMDs) such as depression, anxiety, and somatic complaints.[1] A systematic review of epidemiological studies between 1960 and 2009 in India reported that about 20% of the adult population in the community are affected by psychiatric disorders in the community, ranging from 9.5 to 103/1000 population, with differences in case definitions, and methods of data collection, accounting for most of the variation in estimates.[2]The scheduled tribes (ST) population is a marginalized community and live in relative social isolation with poorer health indices compared to similar nontribal populations.[3] There are an estimated 90 million STs or Adivasis in India.[4] They constitute 8.6% of the total Indian population. The distribution varies across the states and union territories of India, with the highest percentage in Lakshadweep (94.8%) followed by Mizoram (94.4%). In northeastern states, they constitute 65% or more of the total population.[5] The ST communities are identified as culturally or ethnographically unique by the Indian Constitution.

They are populations with poorer health indicators and fewer health-care facilities compared to non-ST rural populations, even when within the same state, and often live in demarcated geographical areas known as ST areas.[4]As per the National Family Health Survey, 2015–2016, the health indicators such as infant mortality rate (IMR) is 44.4, under five mortality rate (U5MR) is 57.2, and anemia in women is 59.8 for STs – one of the most disadvantaged socioeconomic groups in India, which are worse compared to other populations where IMR is 40.7, U5MR is 49.7, and anemia in women among others is 53.0 in the same areas.[6] Little research is available on the health of ST population. Tribal mental health is an ignored and neglected area in the field of health-care services. Further, little data are available about the burden of mental disorders among the tribal communities. Health research on tribal populations is poor, globally.[7] Irrespective of the data available, it is clear that they have worse health indicators and less access to health facilities.[8] Even less is known about the burden of mental disorders in ST population. It is also found that the traditional livelihood system of the STs came into conflict with the forces of modernization, resulting not only in the loss of customary rights over the livelihood resources but also in subordination and further, developing low self-esteem, causing great psychological stress.[4] This community has poor health infrastructure and even less mental health resources, and the situation is worse when compared to other communities living in similar areas.[9],[10]Only 15%–25% of those affected with mental disorders in LMICs receive any treatment for their mental illness,[11] resulting in a large “treatment gap.”[12] Treatment gaps are more in rural populations,[13] especially in ST communities in India, which have particularly poor infrastructure and resources for health-care delivery in general, and almost no capacity for providing mental health care.[14]The aim of this systematic review was to explore the extent and nature of mental health research on ST population in India and to identify gaps and inform future research.

Materials and Methods Search strategyWe searched major databases (PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar) and made hand searches from January 1980 to December 2018 to identify relevant literature. Hand search refers to searching through medical journals which are not indexed in the major electronic databases such as Embase, for instance, searching for Indian journals in IndMed database as most of these journals are not available in major databases. Physical search refers to searching the journals that were not available online or were not available online during the study years. We used relevant Medical Subject Heading and key terms in our search strategy, as follows. €œMental health,” “Mental disorders,” “Mental illness,” “Psychiatry,” “Scheduled Tribe” OR “Tribe” OR “Tribal Population” OR “Indigenous population,” “India,” “Psych*” (Psychiatric, psychological, psychosis).Inclusion criteriaStudies published between January 1980 and December 2018 were included.

Studies on mental disorders were included only when they focused on ST population. Both qualitative and quantitative studies on mental disorders of ST population only were included in the analysis.Exclusion criteriaStudies without any primary data and which are merely overviews and commentaries and those not focused on ST population were excluded from the analysis.Data management and analysisTwo researchers (SD and SK) initially screened the title and abstract of each record to identify relevant papers and subsequently screened full text of those relevant papers. Any disagreements between the researchers were resolved by discussion or by consulting with an adjudicator (PKM). From each study, data were extracted on objectives, study design, study population, study duration, interventions (if applicable), outcomes, and results. Quality of the included studies was assessed, independently by three researchers (SD, SK, and AS), using Critical Appraisal Checklist developed by Critical Appraisal Skills Programme (CASP).[15] After a thorough qualitative assessment, all quantitative data were generated and tabulated.

A narrative description of the studies is provided in [Table 1] using some broad categories. Results Search resultsOur search retrieved 2306 records (which included hand-searched articles), of which after removing duplicates, title and abstracts of 2278 records were screened. Of these, 178 studies were deemed as potentially relevant and were reviewed in detail. Finally, we excluded 146 irrelevant studies and 32 studies were included in the review [Figure 1].Quality of the included studiesSummary of quality assessment of the included studies is reported in [Table 2]. Overall, nine studies were of poor quality, twenty were of moderate quality, and three studies were of high quality.

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

And methods used were not sufficiently described to repeat them. Studies under the moderate quality did not have a representative sample. Non-responders categories was not addressed. Risk factors were not measured correctly. And methods used were not sufficiently described to allow the study to be replicated by other researchers.The included studies covered three broad categories.

Alcohol and substance use disorders, CMD (depression, anxiety, stress, and suicide risk), socio-cultural aspects, and access to mental health services.Alcohol and substance use disordersFive studies reviewed the consumption of alcohol and opioid. In an ethnographic study conducted in three western districts in Rajasthan, 200 opium users were interviewed. Opium consumption was common among both younger and older males during nonharvest seasons. The common causes for using opium were relief of anxiety related to crop failure due to drought, stress, to get a high, be part of peers, and for increased sexual performance.[16]In a study conducted in Arunachal Pradesh involving a population of more than 5000 individuals, alcohol use was present in 30% and opium use in about 5% adults.[17] Contrary to that study, in Rajasthan, the prevalence of opium use was more in women and socioeconomic factors such as occupation, education, and marital status were associated with opium use.[16] The prevalence of opium use increased with age in both sexes, decreased with increasing education level, and increased with employment. It was observed that wages were used to buy opium.

In the entire region of Chamlang district of Arunachal Pradesh, female substance users were almost half of the males among ST population.[17] Types of substance used were tobacco, alcohol, and opium. Among tobacco users, oral tobacco use was higher than smoking. The prevalence of tobacco use was higher among males, but the prevalence of alcohol use was higher in females, probably due to increased access to homemade rice brew generally prepared by women. This study is unique in terms of finding a strong association with religion and culture with substance use.[18]Alcohol consumption among Paniyas of Wayanad district in Kerala is perceived as a male activity, with many younger people consuming it than earlier. A study concluded that alcohol consumption among them was less of a “choice” than a result of their conditions operating through different mechanisms.

In the past, drinking was traditionally common among elderly males, however the consumption pattern has changed as a significant number of younger men are now drinking. Drinking was clustered within families as fathers and sons drank together. Alcohol is easily accessible as government itself provides opportunities. Some employers would provide alcohol as an incentive to attract Paniya men to work for them.[19]In a study from Jharkhand, several ST community members cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol. Societal acceptance of drinking alcohol and peer pressure, as well as high emotional problems, appeared to be the major etiology leading to higher prevalence of substance dependence in tribal communities.[20] Another study found high life time alcohol use prevalence, and the reasons mentioned were increased poverty, illiteracy, increased stress, and peer pressure.[21] A household survey from Chamlang district of Arunachal Pradesh revealed that there was a strong association between opium use and age, occupation, marital status, religion, and ethnicity among both the sexes of STs, particularly among Singhpho and Khamti.[15] The average age of onset of tobacco use was found to be 16.4 years for smoked and 17.5 years for smokeless forms in one study.[22]Common mental disorders and socio-cultural aspectsSuicide was more common among Idu Mishmi in Roing and Anini districts of Arunachal Pradesh state (14.2%) compared to the urban population in general (0.4%–4.2%).

Suicides were associated with depression, anxiety, alcoholism, and eating disorders. Of all the factors, depression was significantly high in people who attempted suicide.[24] About 5% out of 5007 people from thirty villages comprising ST suffered from CMDs in a study from West Godavari district in rural Andhra Pradesh. CMDs were defined as moderate/severe depression and/or anxiety, stress, and increased suicidal risk. Women had a higher prevalence of depression, but this may be due to the cultural norms, as men are less likely to express symptoms of depression or anxiety, which leads to underreporting. Marital status, education, and age were prominently associated with CMD.[14] In another study, gender, illiteracy, infant mortality in the household, having <3 adults living in the household, large family size with >four children, morbidity, and having two or more life events in the last year were associated with increased prevalence of CMD.[24] Urban and rural ST from the same community of Bhutias of Sikkim were examined, and it was found that the urban population experienced higher perceived stress compared to their rural counterparts.[25] Age, current use of alcohol, poor educational status, marital status, social groups, and comorbidities were the main determinants of tobacco use and nicotine dependence in a study from the Andaman and Nicobar Islands.[22] A study conducted among adolescents in the schools of rural areas of Ranchi district in Jharkhand revealed that about 5% children from the ST communities had emotional symptoms, 9.6% children had conduct problems, 4.2% had hyperactivity, and 1.4% had significant peer problems.[27] A study conducted among the female school teachers in Jharkhand examined the effects of stress, marital status, and ethnicity upon the mental health of school teachers.

The study found that among the three factors namely stress, marital status, and ethnicity, ethnicity was found to affect mental health of the school teachers most. It found a positive relationship between mental health and socioeconomic status, with an inverse relationship showing that as income increased, the prevalence of depression decreased.[28] A study among Ao-Nagas in Nagaland found that 74.6% of the population attributed mental health problems to psycho-social factors and a considerable proportion chose a psychiatrist or psychologist to overcome the problem. However, 15.4% attributed mental disorders to evil spirits. About 47% preferred to seek treatment with a psychiatrist and 25% preferred prayers. Nearly 10.6% wanted to seek the help of both the psychiatrist and prayer group and 4.4% preferred traditional healers.[28],[29] The prevalence of Down syndrome among the ST in Chikhalia in Barwani district of Madhya Pradesh was higher than that reported in overall India.

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

The study included 238 adults suffering from CMD. During the intervention period, 12.6% visited the primary health-care doctors compared to only 0.8% who had sought any care for their mental disorders prior to the intervention. The study also found a significant reduction in the depression and anxiety scores at the end of intervention and improvements in stigma perceptions related to mental health.[14] A study in Gudalur and Pandalur Taluks of Nilgiri district from Tamil Nadu used low cost task shifting by providing community education and identifying and referring individuals with psychiatric problems as effective strategies for treating mental disorders in ST communities. Through the program, the health workers established a network within the village, which in turn helped the patients to interact with them freely. Consenting patients volunteered at the educational sessions to discuss their experience about the effectiveness of their treatment.

Community awareness programs altered knowledge and attitudes toward mental illness in the community.[33] A study in Nilgiri district, Tamil Nadu, found that the community had been taking responsibility of the patients with the system by providing treatment closer to home without people having to travel long distances to access care. Expenses were reduced by subsidizing the costs of medicine and ensuring free hospital admissions and referrals to the people.[34] A study on the impact of gender, socioeconomic status, and age on mental health of female factory workers in Jharkhand found that the ST women were more likely to face stress and hardship in life due to diverse economic and household responsibilities, which, in turn, severely affected their mental health.[35] Prevalence of mental health morbidity in a study from the Sunderbans delta found a positive relation with psycho-social stressors and poor quality of life. The health system in that remote area was largely managed by “quack doctors” and faith healers. Poverty, illiteracy, and detachment from the larger community helped reinforce superstitious beliefs and made them seek both mental and physical health care from faith healers.[36] In a study among students, it was found that children had difficulties in adjusting to both ethnic and mainstream culture.[27] Low family income, inadequate housing, poor sanitation, and unhealthy and unhygienic living conditions were some environmental factors contributing to poor physical and mental growth of children. It was observed that children who did not have such risk factors maintained more intimate relations with the family members.

Children belonging to the disadvantaged environment expressed their verbal, emotional need, blame, and harm avoidances more freely than their counterparts belonging to less disadvantaged backgrounds. Although disadvantaged children had poor interfamilial interaction, they had better relations with the members outside family, such as peers, friends, and neighbors.[37] Another study in Jharkhand found that epilepsy was higher among ST patients compared to non-ST patients.[31] Most patients among the ST are irregular and dropout rates are higher among them than the non-ST patients. Urbanization per se exerted no adverse influence on the mental health of a tribal community, provided it allowed preservation of ethnic and cultural practices. Women in the ST communities were less vulnerable to mental illness than men. This might be a reflection of their increased responsibilities and enhanced gender roles that are characteristic of women in many ST communities.[38] Data obtained using culturally relevant scales revealed that relocated Sahariya suffer a lot of mental health problems, which are partially explained by livelihood and poverty-related factors.

The loss of homes and displacement compromise mental health, especially the positive emotional well-being related to happiness, life satisfaction, optimism for future, and spiritual contentment. These are often not overcome even with good relocation programs focused on material compensation and livelihood re-establishment.[39] Discussion This systematic review is to our knowledge the first on mental health of ST population in India. Few studies on the mental health of ST were available. All attempts including hand searching were made to recover both published peer-reviewed papers and reports available on the website. Though we searched gray literature, it may be possible that it does not capture all articles.

Given the heterogeneity of the papers, it was not possible to do a meta-analysis, so a narrative review was done.The quality of the studies was assessed by CASP. The assessment shows that the research conducted on mental health of STs needs to be carried out more effectively. The above mentioned gaps need to be filled in future research by considering the resources effectively while conducting the studies. Mental and substance use disorders contribute majorly to the health disparities. To address this, one needs to deliver evidence-based treatments, but it is important to understand how far these interventions for the indigenous populations can incorporate cultural practices, which are essential for the development of mental health services.[30] Evidence has shown a disproportionate burden of suicide among indigenous populations in national and regional studies, and a global and systematic investigation of this topic has not been undertaken to date.

Previous reviews of suicide epidemiology among indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth, high-income countries, or regions such as Oceania or the Arctic.[46] The only studies in our review which provided data on suicide were in Idu Mishmi, an isolated tribal population of North-East India, and tribal communities from Sunderban delta.[24],[37] Some reasons for suicide in these populations could be the poor identification of existing mental disorders, increased alcohol use, extreme poverty leading to increased debt and hopelessness, and lack of stable employment opportunities.[24],[37] The traditional consumption pattern of alcohol has changed due to the reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement.[19],[20]Faith healers play a dominant role in treating mental disorders. There is less awareness about mental health and available mental health services and even if such knowledge is available, access is limited due to remoteness of many of these villages, and often it involves high out-of-pocket expenditure.[35] Practitioners of modern medicine can play a vital role in not only increasing awareness about mental health in the community, but also engaging with faith healers and traditional medicine practitioners to help increase their capacity to identify and manage CMDs that do not need medications and can be managed through simple “talk therapy.” Knowledge on symptoms of severe mental disorders can also help such faith healers and traditional medicine practitioners to refer cases to primary care doctors or mental health professionals.Remote settlements make it difficult for ST communities to seek mental health care. Access needs to be increased by using solutions that use training of primary health workers and nonphysician health workers, task sharing, and technology-enabled clinical decision support tools.[3] The SMART Mental Health project was delivered in the tribal areas of Andhra Pradesh using those principles and was found to be beneficial by all stakeholders.[14]Given the lack of knowledge about mental health problems among these communities, the government and nongovernmental organizations should collect and disseminate data on mental disorders among the ST communities. More research funding needs to be provided and key stakeholders should be involved in creating awareness both in the community and among policy makers to develop more projects for ST communities around mental health. Two recent meetings on tribal mental health – Round Table Meeting on Mental Health of ST Populations organized by the George Institute for Global Health, India, in 2017,[51] and the First National Conference on Tribal Mental Health organized by the Indian Psychiatric Society in Bhubaneswar in 2018 – have identified some key areas of research priority for mental health in ST communities.

A national-level policy on mental health of tribal communities or population is advocated which should be developed in consultation with key stakeholders. The Indian Psychiatric Society can play a role in coordinating research activities with support of the government which can ensure regular monitoring and dissemination of the research impact to the tribal communities. There is a need to understand how mental health symptoms are perceived in different ST communities and investigate the healing practices associated with distress/disaster/death/loss/disease. This could be done in the form of cross-sectional or cohort studies to generate proper evidence which could also include the information on prevalence, mental health morbidity, and any specific patterns associated with a specific disorder. Future research should estimate the prevalence of mental disorders in different age groups and gender, risk factors, and the influence of modernization.

Studies should develop a theoretical model to understand mental disorders and promote positive mental health within ST communities. Studies should also look at different ST communities as cultural differences exist across them, and there are also differences in socioeconomic status which impact on ability to access care.Research has shown that the impact and the benefits are amplified when research is driven by priorities that are identified by indigenous communities and involve their active participation. Their knowledge and perspectives are incorporated in processes and findings. Reporting of findings is meaningful to the communities. And indigenous groups and other key stakeholders are engaged from the outset.[47] Future research in India on ST communities should also adhere to these broad principles to ensure relevant and beneficial research, which have direct impact on the mental health of the ST communities.There is also a need to update literature related to mental health of ST population continuously.

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

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Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].