Can i get viagra over the counter at walmart

Each year, can i get viagra over the counter at walmart HHS issues a set of rules and guidelines that apply to the health insurance exchanges created by the Affordable Care Act, and to the health plans that are sold in the individual/family market. The rule-making process includes a proposed rule, a public comment period, and then a final rule. This is normally can i get viagra over the counter at walmart a fairly straightforward process, but it’s been more complicated for the upcoming 2022 plan year. The Trump administration issued the proposed 2022 rules in late November last year, and finalized some of them in January, just before inauguration day. In May, the Biden administration finalized the rest of the proposed rule changes, but noted that they intended to propose a new set of rules, with a new public comment period, in order to revisit some of the changes that had been finalized by the outgoing administration.

In late June, the Biden administration published the new proposed rules, and opened a can i get viagra over the counter at walmart new public comment period that continued through July 28. A total of 341 comments were submitted, and are under review by HHS. Some of the new proposals are direct reversals of the rule changes that the Trump administration had made. Others are new ideas that are designed to help more people can i get viagra over the counter at walmart gain access to affordable health insurance. For various provisions, HHS notes that there are pros and cons to the proposals they’re making, and are seeking public feedback before any rules are finalized.

As is always the case, some of the proposed rules are more “behind the scenes” and wouldn’t be particularly noticeable to consumers. But there are some that can i get viagra over the counter at walmart would directly affect consumers, mostly by making it easier to enroll in health coverage. How about an extra month of open enrollment?. For the last several years, the standard open enrollment period has been set at November 1 – December 15. This is the schedule that’s used by HealthCare.gov (the exchange/marketplace in 36 states), although Washington, DC and 14 states run their own exchange platforms and most of them tend to extend open enrollment can i get viagra over the counter at walmart.

HHS has now proposed adding an extra month to open enrollment, so that it would continue through January 15 instead of ending in mid-December. If finalized, this rule change would take effect for the upcoming open enrollment period that starts in November, for coverage effective in 2022. HHS clarifies that the intent here is to give can i get viagra over the counter at walmart people more time to enroll, and give enrollment assisters more time to help everyone who needs it. They also point out that some people don’t realize how much their premiums might change from one year to the next, and are caught off guard when they get their invoice in January. By that point, however, it’s normally too late to change plans, and people might end up dropping their coverage altogether if it’s become too expensive.

By giving people until January 15 to enroll, there’s time for a “do-over” if a policy was allowed can i get viagra over the counter at walmart to auto-renew and then ended up being more expensive than expected. On the other hand, HHS notes that when enrollment ends in mid-December, everyone has full-year coverage, with policies that take effect in January. If enrollment is extended until mid-January, some enrollees will have coverage that takes effect in February instead. Most of the state-run exchanges already offer this, but it would take additional outreach and communication to ensure that consumers are aware that they would still need to enroll by mid-December in order to have coverage in can i get viagra over the counter at walmart effect as of January 1. Year-round enrollment for people with income up to 150% FPL HHS has proposed an ongoing enrollment opportunity for applicants with household income that doesn’t exceed 150% of the federal poverty level.

If finalized, this would allow eligible applicants to enroll in coverage at any time of the year. (Under current rules, enrollment outside of the normal open enrollment period requires a special enrollment period, triggered by a qualifying life can i get viagra over the counter at walmart event). This enrollment opportunity would be offered through the federally run exchange (HealthCare.gov), and state-run exchanges would have the option to offer it. HHS has clarified that it’s uncertain whether this could be added as an option for the 2022 plan year. It might need to be delayed until 2023 to give health plan can i get viagra over the counter at walmart actuaries adequate time to prepare for this change.

The American Rescue Plan, enacted earlier this year, has enhanced the ACA’s premium tax credits (premium subsidies) for 2021 and 2022, providing more financial help for people who buy their own health insurance. As a result, households with income up to 150% of the federal poverty level are eligible for subsidies that fully cover the cost of the benchmark plan. That means they can can i get viagra over the counter at walmart select either of the two lowest-cost Silver plans and have no monthly premium. (They will also tend to have access to a variety of premium-free Bronze plans, and possibly some premium-free Gold plans. But Silver plans are generally the best option for people in this income range, due to the robust cost-sharing reductions that come with Silver plans.) HHS notes that the enhanced premium subsidies would help to prevent adverse selection, since most applicants with household income up to 150% of FPL would be able to enroll in Silver plans — with strong cost-sharing can i get viagra over the counter at walmart reductions — without premiums.

This means that they would be unlikely to drop their coverage after receiving medical care, as they would not have to pay anything to keep the coverage in force. (This would be applicable for 2022, assuming the year-round enrollment option could be added for 2022. For 2023 and future can i get viagra over the counter at walmart years, the availability of zero-premium Silver plans will depend on whether Congress extends the American Rescue Plan’s subsidy enhancements.) However, HHS does note that some enrollees with income up to 150% of FPL do have to pay at least minimal premiums for the benchmark plan. This includes people in states where additional services beyond essential health benefits are required to be covered (and thus the premium subsidy doesn’t cover the entire cost of the benchmark plan) as well as applicants who are subject to a tobacco surcharge. And it’s also possible for a person earning up to 150% of FPL to purchase a Silver plan that’s more expensive than the benchmark plan, and thus have a monthly premium even after the subsidy is applied.

It’s possible that there could be some can i get viagra over the counter at walmart adverse selection among these populations, with enrollees potentially dropping their coverage or shifting to a lower-cost plan after their medical needs are resolved. HHS is seeking public comments about how to best approach this. It’s worth noting that Medicaid and CHIP enrollment is already available year-round, as is Basic Health Program enrollment in the two states where it’s available. In most can i get viagra over the counter at walmart states, Medicaid is available to adults under age 65 with household income up to 138% of the poverty level. The income caps are higher for children to qualify for Medicaid, and CHIP is available to children (and in some cases, pregnant women) in many middle-class households.

So a family with low or modest income can obtain coverage year-round in most states — for the children, and possibly the adults. This is true even though many CHIP programs can i get viagra over the counter at walmart — and some Medicaid programs — charge premiums. Extending open enrollment to run year-round for subsidy-eligible applicants with household income up to 150% of the poverty level would essentially just be an expansion of the enrollment eligibility rules that already exist for lower-income households. Including the ACA’s expansion of Medicaid, health insurance exchanges, and Basic Health Programs, ACA enrollment now encompasses about 10% of all Americans. But there can i get viagra over the counter at walmart are still millions of Americans — most of whom have fairly low incomes — who are uninsured and possibly unaware of the financial assistance that’s available to them.

HHS is working to make coverage as accessible as possible to this population, and the proposed year-round enrollment window is part of that approach. Standardized plans return to HealthCare.gov for 2023 Five years ago, HealthCare.gov debuted standardized health plans, dubbed “Simple Choice” plans. The idea was to make it easier for consumers to compare apples to can i get viagra over the counter at walmart apples when looking at multiple health insurance policy options. The Trump administration finalized a rule change in 2018 that eliminated Simple Choice plans starting with the 2019 plan year. So HHS did not create standardized plan designs for the last few years.

The 2018 rule change that eliminated standardized plan designs on HealthCare.gov was vacated by a court ruling earlier this year, as were three other provisions of the can i get viagra over the counter at walmart 2018 rule. So HHS is starting the process of once again creating standardized plans and gathering public feedback on how to best proceed. And earlier this month, President Biden issued a wide-ranging executive order aimed at promoting competition in the U.S. Economy. One of its provisions calls for HHS to “implement standardized options in the national Health Insurance Marketplace and any other appropriate mechanisms to improve competition and consumer choice.” When standardized plans were previously available in the federally run exchange, it was optional for insurers to offer them and insurers were also free to offer a variety of non-standardized plans.

The specifics of their reintroduction are unclear at this point, but the proposed rules seem to indicate that the plans, which are expected to be available for the 2023 plan year, will continue to be optional for insurers. Consumer protection rules Some of the other proposed rule changes are designed to protect consumers, although their implementation might not be obvious. Over the last few years, HHS had implemented several regulatory changes that would have eroded various consumer protections or created confusion in the marketplace. But these rules have either been blocked by the courts or had little in the way of interest from states. And now HHS has proposed a reversal of some of them.

Insurers are required to collect at least $1/month in premiums to cover the cost of non-Hyde abortion coverage if it’s offered by a health plan. Premium subsidies can’t cover this amount, and insurers must keep the funds segregated from the rest of the premiums they collect. But a previous rule change required insurers to actually send separate invoices for this amount. A judge blocked that rule last year before it took effect, noting that it would lead to widespread consumer confusion. And now HHS is proposing that the rule simply be eliminated altogether.

Insurers would still have to segregate the premiums for abortion services, and they still cannot be covered by premium subsidies. But no separate invoice would be required. The consumer protection guardrails for 1332 waivers were significantly relaxed in 2018. Few states had expressed interest in utilizing the new rules (the vast majority of 1332 waiver proposals have continued to be for reinsurance programs), but HHS is now proposing that the more stringent 1332 waiver guardrails be restored. In January, the outgoing Trump administration finalized a program known as “Exchange Direct Enrollment,” designed to allow states to abandon their ACA-created exchanges altogether and rely instead on broker and insurer websites.

(Note that this is not the same thing as enhanced direct enrollment, which continues to be an option utilized by dozens of enrollment entities.) HHS has now proposed eliminating the Exchange Direct Enrollment option. The public feedback on the Exchange Direct Enrollment program was almost entirely negative, and no states had expressed an interest in pursuing this idea. (Georgia had already received approval for a 1332 waiver utilizing this concept. That approval is now under review by the Biden administration.) The final version of the new rules is expected to be published within the next few weeks. We won’t know the status of these proposed rule changes until then, but the proposed changes we’ve discussed here are fairly likely to be finalized, albeit with possible modifications based on public comments that HHS received.

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.This spring and summer, more than 2 million Americans have already flocked to the health insurance marketplaces in their states, enticed by larger health insurance subsidies during a one-time special enrollment period (SEP). This SEP was created to address the erectile dysfunction treatment viagra and allow people to take advantage of the extra subsidies created by the American Rescue Plan (ARP). But this limited enrollment opportunity is about to end in most states.

There are a few state-run exchanges where the erectile dysfunction treatment-related SEP has already ended, and a few others where it extends past August 15. But in most of the country, August 15 is the last day to sign up for 2021 coverage without needing to show proof of a qualifying life event. How many people bought individual health insurance during the SEP?. HHS reported that 2.1 million people had already enrolled in coverage under this SEP by the end of June. This is two to three times higher than typical enrollment volume during that time of year (when a qualifying event would normally be necessary).

And enrollment likely increased even more in July, when the additional subsidies were made available for people who had received unemployment compensation in 2021. What happens when the SEP ends on August 15?. Once the erectile dysfunction treatment/American Rescue Plan special enrollment period ends in your state, regular individual-market enrollment rules will apply. This means that you’ll need a qualifying event in order to enroll in coverage with a 2021 effective date. The next open enrollment opportunity will start nationwide on November 1, but that enrollment period will be for coverage that takes effect January 1, 2022.

Why review your coverage before the SEP deadline?. Even if you’re already enrolled in a health plan through the marketplace in your state and you’re happy with your coverage, you should take a few minutes to double check everything before the SEP ends. You can update your account to make sure that you’re receiving the enhanced subsidy amount available under the ARP. And if you need to switch plans to best take advantage of that subsidy, now’s your chance to do so. This could be the case, for example, if you’re newly eligible for cost-sharing reductions because you’ve received unemployment benefits this year.

(You need to be enrolled in a Silver plan to receive that benefit.) It could also be the case if you’re currently enrolled in a plan that costs less than your new subsidy amount. You might find that you can upgrade your coverage and still have minimal premiums each month. One thing to note. Before you make a plan change, make sure you understand whether deductible and out-of-pocket amounts will transfer to the new plan. They probably will, as long as you stick with the same insurer.

If you’re enrolled through HealthCare.gov and you don’t update your account to activate the new subsidies, you should still see your subsidy amounts updated as of September. HHS will be updating accounts in August to align the ARP’s subsidy structure with the income amounts that enrollees had previously projected for 2021. This will be helpful in terms of giving people more affordable coverage for the final few months of the year, as opposed to having to wait until tax season to claim the extra subsidy. But there will be no opportunity to change your 2021 coverage at that point, unless you have a qualifying event. Why should you enroll now if you haven’t already?.

Millions of Americans are already enrolled in health coverage through the exchanges. But there are still millions more who are uninsured or enrolled in non-ACA-compliant coverage such as short-term health plans or health care sharing ministry plans. If that’s you or someone you know, the current enrollment period is an excellent opportunity to make the switch to comprehensive major medical health insurance. And chances are, it’ll be less expensive than you’re expecting, especially if it’s been a while since you checked your coverage options. There are several reasons for this.

For 2021 and 2022, the ARP has reduced the amount that people have to pay for their coverage, even if they were already eligible for subsidies. The ARP has also eliminated the “subsidy cliff” for those two years. The law makes subsidies available to households that earn more than 400% of the poverty level, if they would otherwise have to spend more than 8.5% of their income on the benchmark plan. People who have received even one week of unemployment compensation this year are eligible for full premium subsidies and cost-sharing reductions. That means they can get a free (or nearly free) Silver plan, but the benefits will be upgraded to platinum-level.

Will my premiums be higher if I wait until November?. The current SEP is for 2021 coverage, whereas the open enrollment period that starts in November will be for 2022 coverage. If you buy health coverage now, you’ll be locking in your premiums for the rest of this year. In January 2022, your premium is likely to change, though we don’t yet have a clear picture of exactly how premiums will be changing. Across the states where rate filings have been made public, we’re seeing insurers proposing mostly single-digit rate increases, although there have also been some decreases and a handful of larger increases proposed.

But since most marketplace enrollees receive premium subsidies, changes in benchmark premium prices (and the related changes in subsidy amounts) will play a significant role in how much your net premiums change for 2022. Should I enroll before the deadline if I’m uninsured?. If you’re uninsured, there’s no benefit to skipping coverage now and waiting for the start of open enrollment. That will just guarantee that you won’t have coverage in place until January, and your 2022 premium will be the same either way. If a sudden and serious health condition were to arise while you’re uninsured, you would have no way to obtain coverage that starts before January 2022 unless you experience a qualifying event.

When will my coverage start if I enroll during the SEP?. As is always the case, your coverage won’t take effect immediately. If you enroll during the current SEP in most states, your plan will take effect the first of the following month. How long will my coverage last if I enroll by the SEP deadline?. ACA-compliant individual/family health plans renew each year on January 1.

This is true regardless of when you sign up for the plan. So if you’re enrolling during the current SEP, the specifics of your health plan – including the monthly premium – will remain the same through the end of December. (Note that your after-subsidy monthly premium could change if your income changes later in the year.) At that point, your plan will likely be available for renewal for 2022, but the premiums and the coverage details might change. So for example, the deductible and out-of-pocket limit might change, and your premium will almost certainly change – due to both the change in your own plan’s premium, as well as changes to your subsidy amount caused by fluctuations in the benchmark premium amount in your area. If I enroll now, do I need to enroll again in November?.

In most cases, coverage will auto-renew if you don’t log back into your account during the fall open enrollment to manually pick your coverage for 2022. But for a variety of reasons, auto-renewal is not in your best interest. Instead, you should plan to spend at least a few minutes this fall comparing your options for 2022. Even though the open enrollment window is just around the corner (it starts November 1) the options for 2022 might be very different from what you’re seeing right now for the rest of 2021. Insurers are joining the marketplaces in many states, and existing insurers are expanding their coverage areas.

That can affect plan availability as well as subsidy amounts, so you’ll want to plan to spend some time reconsidering your options for 2022. Is there any way to enroll in 2021 coverage after August 15?. In California, DC, New Jersey, New York, and Vermont, the erectile dysfunction treatment-related special enrollment period is already scheduled to extend past August 15. (In Vermont, this applies to uninsured residents. Current enrollees who wish to switch plans must do so by August 15.) But even in those states, it’s in your best interest to enroll sooner rather than later, in order to take advantage of the enhanced subsidies that are available under the American Rescue Plan.

After August 15, in most states, you’ll need a qualifying event to be able to sign up for coverage that starts prior to January 2022. You’ll have access to open enrollment this fall, but that coverage won’t take effect until January, even if you enroll right away on November 1. What do I need to do if I’m getting a COBRA subsidy?. The American Rescue Plan’s COBRA subsidy continues through the end of September. Assuming your COBRA or state continuation coverage is eligible to continue past that date, you’ll have the option to keep it by paying the full premiums yourself as of October, or switch to a self-purchased individual/family plan instead.

If you want to switch to a self-purchased plan, you can enroll in a plan in the marketplace in September and have your new coverage take effect seamlessly on October 1. Although the erectile dysfunction treatment-related special enrollment period will have ended by that point, you’ll be eligible for a special enrollment period triggered by the termination of the COBRA subsidy. If you’re choosing to switch to a new plan when the COBRA subsidy ends, you’ll want to pay close attention to details regarding any deductible and out-of-pocket costs you’ve accumulated this year. As a general rule, you should assume that those will reset to $0 when you switch to an individual market plan. But it’s possible that your insurer might allow you to transfer them if you switch to an individual plan offered by the same insurer that provides your group coverage.

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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How to cite this how much viagra cost article:Singh how much viagra to take OP. Comprehensive Mental Health Action Plan 2013–2030. We must rise how much viagra to take to the challenge. Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development.

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

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

World Health how much viagra to take Organization. 2013. 2.World Health Organization how much viagra to take. Comprehensive Mental Health Action Plan 2013-2030.

Geneva. World Health Organization. 2021. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_811_21 Tables [Table 1]Abstract Background.

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

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

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

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

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

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

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2021 Oct 31];63:418-23. Available from. Https://www.indianjpsychiatry.org/text.asp?.

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

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

Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases. Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded.

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

Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used. The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale.

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

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

Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant.

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

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

The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016). This means that men with alcohol dependence who are more empathic tend to have lesser relapses.

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

Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI]. 1.34–8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI. 2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09–5.77], P = 0.058).

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

Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2]. However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How to can i get viagra over the counter at walmart cite this article:Singh OP click. Comprehensive Mental Health Action Plan 2013–2030. We must rise to the can i get viagra over the counter at walmart challenge. Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development. Further, in September 2021, the 74th World Health Assembly accepted can i get viagra over the counter at walmart the updates to the action plan, including updates to the target options for indicators and implementation.

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

Mental Health can i get viagra over the counter at walmart Action Plan 2013-2020. Geneva. World Health Organization can i get viagra over the counter at walmart. 2013. 2.World Health can i get viagra over the counter at walmart Organization.

Comprehensive Mental Health Action Plan 2013-2030. Geneva. World Health Organization. 2021. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_811_21 Tables [Table 1]Abstract Background. Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence.

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

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

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

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

Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence. Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2021 Oct 31];63:418-23.

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

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

Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases. Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded. As all the available cases were male, the study was restricted to males.

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

The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale. We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement).

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

Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant. Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis.

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

None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1]. The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016).

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

Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58) =2.72, mean difference = 5.10 [95% confidence interval [CI]. 1.34–8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI. 2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09–5.77], P = 0.058). This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71).

Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11). Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2].

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

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

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

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

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

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

As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE. Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications. Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected. Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management.

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

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Alcohol Res Health 2010;33:55-63. 3.DiClemente CC. Conceptual models and applied research. The ongoing contribution of the transtheoretical model. J Addict Nurs 2005;16:5-12.

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

J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of “motivation for change” in psychoanalytic treatment. Int J Psychoanal 1972;53:51-9. 7.Miller WR.

Motivation for treatment. A review with special emphasis on alcoholism. Psychol Bull 1985;98:84-107. 8.Murphy PN, Bentall RP. Motivation to withdraw from heroin.

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

Alcohol Clin Exp Res 2011;35:1662-8. 10.de Vignemont F, Singer T. The empathic brain. How, when and why?. Trends Cogn Sci 2006;10:435-41.

11.Reniers RL, Corcoran R, Drake R, Shryane NM, Völlm BA. The QCAE. A questionnaire of cognitive and affective empathy. J Pers Assess 2011;93:84-95. 12.Martinotti G, Di Nicola M, Tedeschi D, Cundari S, Janiri L.

Empathy ability is impaired in alcohol-dependent patients. Am J Addict 2009;18:157-61. 13.McCown W. The relationship between impulsivity, empathy and involvement in twelve step self-help substance abuse treatment groups. Br J Addict 1989;84:391-3.

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

J Adolesc 2006;29:589-611. 16.McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy. Measurement and sample profiles. Psychol Psychother 1983;20:368-75.

17.Ferrari V, Smeraldi E, Bottero G, Politi E. Addiction and empathy. A preliminary analysis. Neurol Sci 2014;35:855-9. 18.Massey SH, Newmark RL, Wakschlag LS.

Explicating the role of empathic processes in substance use disorders. A conceptual framework and research agenda. Drug Alcohol Rev 2018;37:316-32. 19.Uekermann J, Daum I. Social cognition in alcoholism.

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

21.Gonzalez-Liencres C, Shamay-Tsoory SG, Brüne M. Towards a neuroscience of empathy. Ontogeny, phylogeny, brain mechanisms, context and psychopathology. Neurosci Biobehav Rev 2013;37:1537-48. 22.Miller PA, Eisenberg N.

The relation of empathy to aggressive and externalizing/antisocial behavior. Psychol Bull 1988;103:324-44. 23.McCown W. The effect of impulsivity and empathy on abstinence of poly-substance abusers. A prospective study.

Br J Addict 1990;85:635-7. 24.Pitel AL, Beaunieux H, Witkowski T, Vabret F, Guillery-Girard B, Quinette P, et al. Genuine episodic memory deficits and executive dysfunctions in alcoholic subjects early in abstinence. Alcohol Clin Exp Res 2007;31:1169-78. 25.Thoma P, Friedmann C, Suchan B.

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

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

Curr Dir Psychol Sci 2006;15:54-8. 29.Tarter RE, Edwards K. Psychological factors associated with the risk for alcoholism. Alcohol Clin Exp Res 1988;12:471-80. 30.Moyers TB, Miller WR.

Is low therapist empathy toxic?. Psychol Addict Behav 2013;27:878-84. 31.Heather N. Psychology and brief interventions. Br J Addict 1989;84:357-70.

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

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

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Kate, 12, has been in therapy for years can i buy viagra over the counter at walgreens to cope with sensory processing disorder, attention deficit hyperactivity disorder and anxiety. When she became suicidal at the age of 8, her therapist advised her parents to take her to the emergency room.Credit...Rachel Woolf for The New York TimesSkip to contentSkip to site indexA Mental Health Crisis Flares can i buy viagra over the counter at walgreens Among Young ChildrenThe number of children under 13 who need urgent mental health care has been on the rise.Kate, 12, has been in therapy for years to cope with sensory processing disorder, attention deficit hyperactivity disorder and anxiety. When she became suicidal at the age of 8, her therapist advised her parents to take her to can i buy viagra over the counter at walgreens the emergency room.Credit...Rachel Woolf for The New York TimesSupported byContinue reading the main storyJune 28, 2021When Marie, 11, called a suicide prevention hotline in October, nobody saw it coming. Not even Marie herself, who had been bottling can i buy viagra over the counter at walgreens up feelings of loneliness and sadness for months without telling anyone.Her relationships with some of her closest friends had started to suffer when school went online last year, and she worried about losing other people in her life, too. What if can i buy viagra over the counter at walgreens they moved away?.

What if can i buy viagra over the counter at walgreens they died?. One weekday afternoon, she put on her headphones and listened to music can i buy viagra over the counter at walgreens while taking a walk, and she began to get increasingly upset. Even now, she can i buy viagra over the counter at walgreens isn’t sure exactly why.“I knew that I needed help, but I didn’t really know who to go to,” she said.She searched for a suicide prevention hotline on her phone, and wondered momentarily whether the crisis counselors would take her seriously. Then, she called.With Marie’s can i buy viagra over the counter at walgreens permission, a counselor conferenced in Marie’s mother, Jackie, who was a 25-minute car ride away. They came can i buy viagra over the counter at walgreens up with a plan to keep Marie safe until Jackie could arrive.

(Their surname and those can i buy viagra over the counter at walgreens of other families interviewed for this article are being withheld to protect their privacy. Marie is being identified by her middle name.)The next day, Marie told her mother that “in the past, can i buy viagra over the counter at walgreens not too long before that, she had brought scissors in her bedroom with the intention of hurting herself, but didn’t know how to,” Jackie said. €œI was completely blindsided.” It wasn’t as though Jackie was unaware of the mental health can i buy viagra over the counter at walgreens crisis affecting adolescents. She works as a nurse at two different pediatric intensive care units on can i buy viagra over the counter at walgreens the East Coast, where she has treated many children who attempted suicide in the past year.“Some of them we’ve asked, ‘How did you get the idea to do this?. €™â€ Social media is their typical can i buy viagra over the counter at walgreens response, she said.

€œThey don’t grasp that if they hurt themselves, it might not be something we can fix, and they might not get better.”Interviews with mental health providers and data from hospitals across the country reveal that while providers are continuing to see a surge in teenagers visiting can i buy viagra over the counter at walgreens the emergency room for mental health problems, the number of children in crisis under the age of 13 is also on the rise, and has been for years. The youngest patient under Jackie’s care who had recently attempted can i buy viagra over the counter at walgreens suicide was 8 years old. She survived, can i buy viagra over the counter at walgreens but another child, also under 13, was not as fortunate, and became an organ donor. Jackie said that most of the children who come in can i buy viagra over the counter at walgreens after suicide attempts are girls who have overdosed on pain medication, like Tylenol. Some of can i buy viagra over the counter at walgreens them now face liver damage.

Once, after a particularly difficult day at work, Jackie called her husband and asked him to lock up all the can i buy viagra over the counter at walgreens Tylenol and Motrin in their home.“I don’t want to ever think we’re immune to these things,” she said.‘We will see this crisis grow in the fall.’Even before the viagra, a mental health crisis was brewing among children struggling with bullying, abuse, eating disorders, racism or undiagnosed mental health conditions. But now, children are facing even more stressors, like the loss of a family member can i buy viagra over the counter at walgreens to erectile dysfunction treatment, adjusting to remote school or the anxiety of returning to in-person school.“It’s almost like the viagra threw gasoline on embers that were already glowing,” said Heather C. Huszti, chief psychologist at Children’s Hospital of Orange County in can i buy viagra over the counter at walgreens Orange, Calif. €œWe’ve never seen it this bad.”For young children, the pain can feel endless.“It’s like, ‘This is my life now can i buy viagra over the counter at walgreens. Do I have anything to look forward to? can i buy viagra over the counter at walgreens.

€™â€ Dr can i buy viagra over the counter at walgreens. Huszti said can i buy viagra over the counter at walgreens. €œBecause they just can’t think long term.”CHOC, where Dr can i buy viagra over the counter at walgreens. Huszti works, has the only inpatient psychiatric center in Orange County that can can i buy viagra over the counter at walgreens take children under 12. In order to be admitted to one of the center’s can i buy viagra over the counter at walgreens 18 beds, a child must be a current or imminent threat to themselves or to others.

When the center first opened in 2018, about can i buy viagra over the counter at walgreens 10 percent of the children were under the age of 12. In 2020, that number began to increase, and now has more than can i buy viagra over the counter at walgreens doubled, Dr. Huszti said.“We have some days where every kid in can i buy viagra over the counter at walgreens the unit is under 12,” she said.National data shows a similar pattern. In November, the Centers for Disease Control and Prevention published a study that compared how often children came to emergency rooms in the can i buy viagra over the counter at walgreens United States for mental health reasons versus other types of concerns. The agency found that between April can i buy viagra over the counter at walgreens and October of 2020, there was a 24 percent increase in the proportion of mental health emergency department visits for kids ages 5 to 11 compared with the same period in 2019.The problem appears to be particularly dire among girls.

During 2019 and 2020, the proportion of mental health-related emergency department visits was higher for girls under 18 than can i buy viagra over the counter at walgreens it was for boys of the same age, the C.D.C. Reported.“I anticipate that we will see this crisis grow in can i buy viagra over the counter at walgreens the fall as kids return to school and are trying to adjust to making up for a year of lost development,” said Dr. Jenna Glover, can i buy viagra over the counter at walgreens a child psychologist at Children’s Hospital Colorado in Aurora.Among children who die by suicide, there are stark racial disparities. The rate of suicide can i buy viagra over the counter at walgreens in Black children under 13 has been increasing over the last decade and is two times higher than among white children. In two editorials published on Monday in JAMA Pediatrics, the authors can i buy viagra over the counter at walgreens called on funding agencies and journals to prioritize research on Black youth suicide.

And emphasized the need for preventive efforts that target stigma and institutional racism.‘The younger the child is, the longer they can i buy viagra over the counter at walgreens wait.’Children’s hospitals, which typically have few (if any) available inpatient beds for mental health patients, have begun to run out of room.“The younger the child is, the longer they wait,” Dr. Huszti said can i buy viagra over the counter at walgreens. €œIt just breaks my heart.”With the help of therapy, medication and support from friends and family, can i buy viagra over the counter at walgreens Kate has learned how to manage some of the tough emotions that crept up during lockdown and after her grandfather recently died of cancer. Credit...Rachel Woolf for The New York TimesSome inpatient psychiatric units may not be able to admit kids under 12, she added, because they often require more one-on-one monitoring than older kids, as well as age-specific therapy.In April, 11-year-old Lu and her mother, Nicole (their middle names), had to wait in can i buy viagra over the counter at walgreens an emergency room in Ohio “all day and all night” because the hospital’s 13 pediatric beds were full and two kids were in line ahead of her. They were eventually transferred to can i buy viagra over the counter at walgreens a behavioral health hospital nearby.

Lu befriended other kids there who had their own mental health struggles, including some who were can i buy viagra over the counter at walgreens several years older. At one point, she saw someone get can i buy viagra over the counter at walgreens sedated and restrained.“I was concerned,” Nicole said. €œShe was exposed to so much there that I wouldn’t want her can i buy viagra over the counter at walgreens to be exposed to.”During the viagra, Lu underwent “a really big personality change” that Nicole attributed to the “perfect storm” of isolation, hormones and genetics. (Nicole was diagnosed with depression and anxiety when she was in her early 20s.) Lu became immersed in social media, and appeared to be caught in an algorithm that kept showing her videos of sad kids, her mother said.“I had to actually explain that to her,” can i buy viagra over the counter at walgreens Nicole said. €œI was like, ‘Hey did you know if I like a picture of a pair of can i buy viagra over the counter at walgreens tennis shoes, I’m going to probably keep seeing pictures of tennis shoes?.

€™ And she looked at me, can i buy viagra over the counter at walgreens and she was like, ‘Really?. €™â€A couple of months ago, Nicole had the sudden urge to check the can i buy viagra over the counter at walgreens text messages saved on her daughter’s tablet. That was when she discovered that Lu had been planning on harming herself and had also written a can i buy viagra over the counter at walgreens goodbye letter.How did we get here?. Even though can i buy viagra over the counter at walgreens the stigma surrounding mental health care has declined somewhat in recent years, “we have not yet given people the skill set or the resources to know how to manage their mental health, how to prevent or how to respond to suicidal thoughts,” said Dr. Christine Moutier, chief medical officer of the can i buy viagra over the counter at walgreens American Foundation for Suicide Prevention.Many children also have underlying psychological problems that simply aren’t being addressed.

A study published in JAMA Pediatrics found that in 2016 half of the estimated 7.7 million children in the United States with a treatable mental health disorder did can i buy viagra over the counter at walgreens not receive treatment from a mental health professional.Finding a provider can be difficult. The American Academy of Child and Adolescent Psychiatry reported that there is a severe can i buy viagra over the counter at walgreens shortage of child psychiatrists in nearly every state in the country. In California, for example, there are only 13 practicing child and adolescent psychiatrists for every 100,000 children under 18.Insurance companies don’t reimburse mental health services as highly as they do medical services, which makes it far less profitable for providers to treat mental health can i buy viagra over the counter at walgreens patients, experts say. For example, in Connecticut, Medicaid reimburses can i buy viagra over the counter at walgreens hospitals $2,665 per day for a standard pediatric inpatient admission and about $1,000 per day for a pediatric psychiatric hospitalization, said Ryan Calhoun, the vice president of strategy and care integration at Connecticut Children’s.Finally, the American Academy of Pediatrics recommends mental health screening for all children 12 and older during well-child visits, but it is not standard practice to screen children younger than that, said Dr. Tami D can i buy viagra over the counter at walgreens.

Benton, psychiatrist-in-chief of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia.“Previously, the under-12’s were identified as a low-risk group,” she said.That’s not the case anymore, she added.Kate, who lives in Colorado, was in the third grade when she told her parents that she didn’t want to live anymore can i buy viagra over the counter at walgreens. For much of her childhood, she has suffered from sensory processing can i buy viagra over the counter at walgreens disorder, attention deficit hyperactivity disorder and anxiety, and she was bullied in elementary school.“I felt like I was just a waste of space,” Kate, who is now 12, said in an interview. €œI was in so much pain.”Back when she was 8, her parents took her to the emergency room, where they stayed for about 12 hours until it was determined that Kate would be safe at home.“You just feel can i buy viagra over the counter at walgreens like, gosh, what have I done wrong as a parent?. How am can i buy viagra over the counter at walgreens I not supporting my kid?. € said Hope, Kate’s mother.“Don’t feel shame,” can i buy viagra over the counter at walgreens she advised other parents.

Instead, take a deep breath and call the pediatrician or a crisis line, Hope can i buy viagra over the counter at walgreens said, “so that you don’t feel alone.”‘There’s no place to send them.’Connecticut Children’s hospital in Hartford does not have any inpatient beds for pediatric psychiatric patients. It takes an average of one week before kids in the emergency room can find a bed elsewhere, Dr can i buy viagra over the counter at walgreens. Jennifer Downs, the division head of child and adolescent psychiatry at Connecticut Children’s, said during an interview in late May.On that particular day, can i buy viagra over the counter at walgreens 10 of the 37 children in the emergency room for mental health reasons were under 13. Some children wait for an inpatient bed for as long can i buy viagra over the counter at walgreens as a month, she added.“There’s no place to send them,” said James E. Shmerling, the can i buy viagra over the counter at walgreens president and chief executive at Connecticut Children’s.

€œEvery existing can i buy viagra over the counter at walgreens resource in the community has a backlog.”In Colorado, the situation is also critical. This year, at any given time, about half of the kids in the pediatric emergency department at Children’s Hospital Colorado are experiencing a mental health crisis, which prompted the institution to declare a state of emergency in May.Not only are Colorado’s emergency rooms full, so are can i buy viagra over the counter at walgreens the long-term pediatric residential facilities. More than 70 children with severe mental illness had to go out of state to find a residential treatment program over the last year and a half, some traveling as far as South Carolina, Florida or New York, said Heidi Baskfield, the vice president of population health can i buy viagra over the counter at walgreens and advocacy at Children’s Hospital Colorado. It’s a problem that other can i buy viagra over the counter at walgreens states, including Connecticut, are grappling with too.Searching for solutions.Health care institutions have been scrambling to find ways to treat more children with acute mental health needs. CHOC, for example, is planning to open an intensive outpatient program in the next year for children in middle school who are suicidal as well as a can i buy viagra over the counter at walgreens program to offer specialized therapy to children who are 8 and under.At Children’s Hospital of the King’s Daughters in Virginia, there was a 300 percent increase in mental health emergency department visits among 2- to 12-year-olds from 2015 to 2020.

The hospital is in the process of expanding can i buy viagra over the counter at walgreens its outpatient program to include group therapy for nearly all children, which will allow them to be treated faster than they would have if they needed to wait for one-on-one therapy, said Dr. Mary Margaret Gleason, a pediatrician and child and adolescent psychiatrist there.“The emergency room situation is a crisis, but it will be can i buy viagra over the counter at walgreens fixed only if we look at the preventive efforts that come well before,” said Dr. Gleason, who has can i buy viagra over the counter at walgreens a special interest in working with children under 6. €œWhen you get into the preschool age, the level of unmet needs is extraordinary.”The hospital is also constructing a new building that will have 60 inpatient psychiatric beds — currently they have none — including units for children with neurodevelopmental disorders and kids with concurrent physical and mental health needs, for example diabetes and depression.Connecticut Children’s is educating teachers and pediatricians can i buy viagra over the counter at walgreens about how to manage children with behavioral and mental health conditions, and provides them with a phone number for real-time advice from a mental health professional, Dr. Shmerling said can i buy viagra over the counter at walgreens.

He is hoping to add a medical psychiatric unit to the hospital — with as many as 15 beds can i buy viagra over the counter at walgreens — next year.Some states, including Colorado, are starting to funnel more money toward mental health services, though providers say even more is needed.“For now, we do need beds to meet the surge,” Ms. Baskfield said can i buy viagra over the counter at walgreens. But, she added, children also need support from schools and at the primary care and outpatient level so that fewer of them require intensive care.“We can’t build our way out of this crisis,” she said.If you are having thoughts of suicide, call can i buy viagra over the counter at walgreens the National Suicide Prevention Lifeline. 1-800-273-8255 (TALK) can i buy viagra over the counter at walgreens or text TALK to 741741. .css-1dv1kvn{border:0;-webkit-clip:rect(0 0 0 0);clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;}.css-1kxrhf3{white-space:pre-wrap;}.css-13o7eu2{display:block;}.css-r3w21j{display:block;margin-bottom:20px;grid-column:1;}@media (min-width:880px){.css-r3w21j{margin-bottom:24px;}.nytapp-vi-interactive .css-r3w21j,.nytapp-hybrid-article .css-r3w21j,.nytapp-vi-article .css-r3w21j,.nytapp-vi-liveblog 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€œIf this feels different, or at all off, you should act on can i buy viagra over the counter at walgreens that right away,” she said.Don’t hesitate to use one of these free, 24-7 resources.The National Suicide Prevention Lifeline. 1-800-273-8255 (TALK)The can i buy viagra over the counter at walgreens Crisis Text Line. Text TALK to 741741Or visit the American Foundation can i buy viagra over the counter at walgreens for Suicide Prevention.7m agoItem 1 of 7 AdvertisementContinue reading the main story.

Kate, 12, has been in therapy for years to cope with sensory processing disorder, http://leafyourmark.com/?p=1 attention can i get viagra over the counter at walmart deficit hyperactivity disorder and anxiety. When she became suicidal at the age of 8, her therapist advised her parents to take her to the emergency room.Credit...Rachel Woolf for The New York TimesSkip to contentSkip to site indexA Mental Health Crisis Flares Among Young ChildrenThe number of children under 13 who need urgent mental health care has been on the rise.Kate, 12, has been in therapy for years to can i get viagra over the counter at walmart cope with sensory processing disorder, attention deficit hyperactivity disorder and anxiety. When she became suicidal at the age of 8, her therapist advised her parents to take her to the emergency room.Credit...Rachel Woolf for The New York TimesSupported byContinue reading the main storyJune 28, 2021When Marie, 11, called a suicide prevention hotline in can i get viagra over the counter at walmart October, nobody saw it coming. Not even Marie herself, who had been bottling up feelings of loneliness and sadness for months without telling anyone.Her relationships with some of her closest friends can i get viagra over the counter at walmart had started to suffer when school went online last year, and she worried about losing other people in her life, too. What if can i get viagra over the counter at walmart they moved away?.

What if they can i get viagra over the counter at walmart died?. One weekday can i get viagra over the counter at walmart afternoon, she put on her headphones and listened to music while taking a walk, and she began to get increasingly upset. Even now, she isn’t sure exactly why.“I knew that I needed help, but I didn’t really know who to go to,” she said.She searched for a suicide prevention hotline on her phone, and wondered momentarily can i get viagra over the counter at walmart whether the crisis counselors would take her seriously. Then, she called.With can i get viagra over the counter at walmart Marie’s permission, a counselor conferenced in Marie’s mother, Jackie, who was a 25-minute car ride away. They came up with a plan can i get viagra over the counter at walmart to keep Marie safe until Jackie could arrive.

(Their surname and those of other families interviewed for this article are being can i get viagra over the counter at walmart withheld to protect their privacy. Marie is being identified by her middle name.)The next day, Marie told her mother that “in the past, not too long before that, she had brought can i get viagra over the counter at walmart scissors in her bedroom with the intention of hurting herself, but didn’t know how to,” Jackie said. €œI was completely blindsided.” It wasn’t as though can i get viagra over the counter at walmart Jackie was unaware of the mental health crisis affecting adolescents. She works as a nurse at two different pediatric intensive care units on the East Coast, where she has can i get viagra over the counter at walmart treated many children who attempted suicide in the past year.“Some of them we’ve asked, ‘How did you get the idea to do this?. €™â€ Social media can i get viagra over the counter at walmart is their typical response, she said.

€œThey don’t grasp that if they hurt themselves, it might not be something can i get viagra over the counter at walmart we can fix, and they might not get better.”Interviews with mental health providers and data from hospitals across the country reveal that while providers are continuing to see a surge in teenagers visiting the emergency room for mental health problems, the number of children in crisis under the age of 13 is also on the rise, and has been for years. The youngest patient under Jackie’s care who had recently attempted suicide was 8 years can i get viagra over the counter at walmart old. She survived, but another can i get viagra over the counter at walmart child, also under 13, was not as fortunate, and became an organ donor. Jackie said that most of the children can i get viagra over the counter at walmart who come in after suicide attempts are girls who have overdosed on pain medication, like Tylenol. Some of them now can i get viagra over the counter at walmart face liver damage.

Once, after a particularly difficult day at work, Jackie called her husband and asked him to lock up all the Tylenol and Motrin in their can i get viagra over the counter at walmart home.“I don’t want to ever think we’re immune to these things,” she said.‘We will see this crisis grow in the fall.’Even before the viagra, a mental health crisis was brewing among children struggling with bullying, abuse, eating disorders, racism or undiagnosed mental health conditions. But now, children are facing even more stressors, like the loss of a family member to erectile dysfunction treatment, adjusting to remote school or the can i get viagra over the counter at walmart anxiety of returning to in-person school.“It’s almost like the viagra threw gasoline on embers that were already glowing,” said Heather C. Huszti, chief psychologist at Children’s Hospital of Orange County in Orange, Calif can i get viagra over the counter at walmart. €œWe’ve never seen it this bad.”For young children, the pain can feel can i get viagra over the counter at walmart endless.“It’s like, ‘This is my life now. Do I have anything to look forward to? can i get viagra over the counter at walmart.

€™â€ Dr can i get viagra over the counter at walmart. Huszti said can i get viagra over the counter at walmart. €œBecause they can i get viagra over the counter at walmart just can’t think long term.”CHOC, where Dr. Huszti works, has the only inpatient psychiatric center in Orange can i get viagra over the counter at walmart County that can take children under 12. In order to be admitted to one of the center’s 18 beds, can i get viagra over the counter at walmart a child must be a current or imminent threat to themselves or to others.

When the center first opened in 2018, about 10 percent of can i get viagra over the counter at walmart the children were under the age of 12. In 2020, that number began to increase, and now has more than can i get viagra over the counter at walmart doubled, Dr. Huszti said.“We have some days where every kid in the unit is can i get viagra over the counter at walmart under 12,” she said.National data shows a similar pattern. In November, the Centers for Disease Control and Prevention published a study that compared how often children came to emergency rooms in the United States for can i get viagra over the counter at walmart mental health reasons versus other types of concerns. The agency found that between April and October of 2020, there was can i get viagra over the counter at walmart a 24 percent increase in the proportion of mental health emergency department visits for kids ages 5 to 11 compared with the same period in 2019.The problem appears to be particularly dire among girls.

During 2019 and 2020, the proportion can i get viagra over the counter at walmart of mental health-related emergency department visits was higher for girls under 18 than it was for boys of the same age, the C.D.C. Reported.“I anticipate that we will see this can i get viagra over the counter at walmart crisis grow in the fall as kids return to school and are trying to adjust to making up for a year of lost development,” said Dr. Jenna Glover, a child psychologist at Children’s Hospital Colorado in Aurora.Among children who die can i get viagra over the counter at walmart by suicide, there are stark racial disparities. The rate of suicide in Black children under 13 has been increasing over can i get viagra over the counter at walmart the last decade and is two times higher than among white children. In two editorials published on Monday in JAMA Pediatrics, the authors called on funding agencies and journals to prioritize can i get viagra over the counter at walmart research on Black youth suicide.

And emphasized the need for preventive efforts that target stigma and institutional racism.‘The younger the child is, the can i get viagra over the counter at walmart longer they wait.’Children’s hospitals, which typically have few (if any) available inpatient beds for mental health patients, have begun to run out of room.“The younger the child is, the longer they wait,” Dr. Huszti said can i get viagra over the counter at walmart. €œIt just breaks my heart.”With the can i get viagra over the counter at walmart help of therapy, medication and support from friends and family, Kate has learned how to manage some of the tough emotions that crept up during lockdown and after her grandfather recently died of cancer. Credit...Rachel Woolf for The New York TimesSome inpatient psychiatric units may not be able to admit kids under 12, she added, because they often require more one-on-one monitoring than older kids, as well as age-specific therapy.In April, 11-year-old Lu and her mother, Nicole (their middle names), had to wait in an emergency room in Ohio “all day and all can i get viagra over the counter at walmart night” because the hospital’s 13 pediatric beds were full and two kids were in line ahead of her. They were eventually transferred to a behavioral health hospital nearby can i get viagra over the counter at walmart.

Lu befriended other kids there who can i get viagra over the counter at walmart had their own mental health struggles, including some who were several years older. At one can i get viagra over the counter at walmart point, she saw someone get sedated and restrained.“I was concerned,” Nicole said. €œShe was exposed to so much there that I wouldn’t want her to be exposed to.”During the viagra, Lu underwent “a really big personality change” can i get viagra over the counter at walmart that Nicole attributed to the “perfect storm” of isolation, hormones and genetics. (Nicole was diagnosed with depression and anxiety when she was in her early 20s.) Lu became immersed in social media, and appeared to be caught in an algorithm that kept showing her videos of sad kids, her mother said.“I had to actually can i get viagra over the counter at walmart explain that to her,” Nicole said. €œI was like, ‘Hey did you know if I like a picture of a pair of tennis can i get viagra over the counter at walmart shoes, I’m going to probably keep seeing pictures of tennis shoes?.

€™ And she can i get viagra over the counter at walmart looked at me, and she was like, ‘Really?. €™â€A couple of months ago, Nicole had the sudden urge to check the text messages can i get viagra over the counter at walmart saved on her daughter’s tablet. That was when she discovered that Lu had been planning on harming can i get viagra over the counter at walmart herself and had also written a goodbye letter.How did we get here?. Even though the stigma surrounding mental health care has declined somewhat in recent years, “we have not yet given people the skill set or the resources to know how to manage their mental health, how to prevent or how can i get viagra over the counter at walmart to respond to suicidal thoughts,” said Dr. Christine Moutier, chief medical officer of the American Foundation for Suicide Prevention.Many children also have underlying psychological problems that simply aren’t being can i get viagra over the counter at walmart addressed.

A study published in JAMA Pediatrics found that in 2016 half of the estimated 7.7 million children in the United States can i get viagra over the counter at walmart with a treatable mental health disorder did not receive treatment from a mental health professional.Finding a provider can be difficult. The American Academy of Child and Adolescent https://mycopd-blog.com/2020/02/10/immer-diese-routine/ Psychiatry can i get viagra over the counter at walmart reported that there is a severe shortage of child psychiatrists in nearly every state in the country. In California, for example, there are only 13 practicing child and adolescent psychiatrists for every 100,000 children under 18.Insurance companies don’t reimburse mental health services as highly as they do medical can i get viagra over the counter at walmart services, which makes it far less profitable for providers to treat mental health patients, experts say. For example, in Connecticut, Medicaid reimburses hospitals $2,665 per day for a standard pediatric inpatient can i get viagra over the counter at walmart admission and about $1,000 per day for a pediatric psychiatric hospitalization, said Ryan Calhoun, the vice president of strategy and care integration at Connecticut Children’s.Finally, the American Academy of Pediatrics recommends mental health screening for all children 12 and older during well-child visits, but it is not standard practice to screen children younger than that, said Dr. Tami D can i get viagra over the counter at walmart.

Benton, psychiatrist-in-chief of child and adolescent psychiatry and behavioral sciences at Children’s Hospital of Philadelphia.“Previously, the under-12’s were identified as a low-risk group,” she said.That’s not the case anymore, she added.Kate, who lives in Colorado, was in can i get viagra over the counter at walmart the third grade when she told her parents that she didn’t want to live anymore. For much of her childhood, she has suffered from sensory processing disorder, can i get viagra over the counter at walmart attention deficit hyperactivity disorder and anxiety, and she was bullied in elementary school.“I felt like I was just a waste of space,” Kate, who is now 12, said in an interview. €œI was in so much pain.”Back when she was 8, her parents took her to the emergency room, where they stayed for about 12 hours until it was determined that Kate would be safe at home.“You just feel like, gosh, what have can i get viagra over the counter at walmart I done wrong as a parent?. How am I not can i get viagra over the counter at walmart supporting my kid?. € said Hope, Kate’s mother.“Don’t feel shame,” she can i get viagra over the counter at walmart advised other parents.

Instead, take a deep breath and call the pediatrician or a crisis line, Hope said, “so that you don’t feel alone.”‘There’s no place to send them.’Connecticut Children’s hospital in can i get viagra over the counter at walmart Hartford does not have any inpatient beds for pediatric psychiatric patients. It takes an average of one week before kids can i get viagra over the counter at walmart in the emergency room can find a bed elsewhere, Dr. Jennifer Downs, the division head of child and adolescent psychiatry at Connecticut Children’s, said during an can i get viagra over the counter at walmart interview in late May.On that particular day, 10 of the 37 children in the emergency room for mental health reasons were under 13. Some children wait for an inpatient bed for as long as a month, she added.“There’s no place to send them,” said James can i get viagra over the counter at walmart E. Shmerling, the can i get viagra over the counter at walmart president and chief executive at Connecticut Children’s.

€œEvery existing resource in the community has a backlog.”In Colorado, the situation can i get viagra over the counter at walmart is also critical. This year, at any given time, about half of the kids in the pediatric emergency department at Children’s Hospital Colorado are experiencing a mental health crisis, which prompted the institution to declare a state can i get viagra over the counter at walmart of emergency in May.Not only are Colorado’s emergency rooms full, so are the long-term pediatric residential facilities. More than 70 children with severe mental illness had to go out of state to find a residential treatment program over the last year and a half, some traveling as far as can i get viagra over the counter at walmart South Carolina, Florida or New York, said Heidi Baskfield, the vice president of population health and advocacy at Children’s Hospital Colorado. It’s a problem that other states, including Connecticut, are grappling with too.Searching for solutions.Health care institutions have been scrambling to find ways to treat more can i get viagra over the counter at walmart children with acute mental health needs. CHOC, for example, is planning to open an intensive outpatient program can i get viagra over the counter at walmart in the next year for children in middle school who are suicidal as well as a program to offer specialized therapy to children who are 8 and under.At Children’s Hospital of the King’s Daughters in Virginia, there was a 300 percent increase in mental health emergency department visits among 2- to 12-year-olds from 2015 to 2020.

The hospital is in the process of expanding its outpatient program to include can i get viagra over the counter at walmart group therapy for nearly all children, which will allow them to be treated faster than they would have if they needed to wait for one-on-one therapy, said Dr. Mary Margaret Gleason, a can i get viagra over the counter at walmart pediatrician and child and adolescent psychiatrist there.“The emergency room situation is a crisis, but it will be fixed only if we look at the preventive efforts that come well before,” said Dr. Gleason, who has a special interest in working with children under 6 can i get viagra over the counter at walmart. €œWhen you get into the preschool age, the level of unmet needs is extraordinary.”The hospital is also constructing a new building that will have 60 inpatient psychiatric beds — currently they have none — including units for children with neurodevelopmental disorders and kids with concurrent physical and mental health needs, for example diabetes and depression.Connecticut Children’s is educating teachers and can i get viagra over the counter at walmart pediatricians about how to manage children with behavioral and mental health conditions, and provides them with a phone number for real-time advice from a mental health professional, Dr. Shmerling said can i get viagra over the counter at walmart.

He is hoping to add a medical psychiatric unit to the hospital — with as many as 15 beds — next year.Some states, including Colorado, are starting to funnel more money toward mental health services, though providers say even more is needed.“For now, we do need beds to meet can i get viagra over the counter at walmart the surge,” Ms. Baskfield said can i get viagra over the counter at walmart. 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The Lake Cathie community will have a new purpose-built ambulance station thanks to a NSW Government boost of $100 million to ambulance infrastructure in rural NSW.Minister for Health Brad Hazzard said the initial $122 million Rural Ambulance Infrastructure Reconfiguration (RAIR) program had proved such a success the NSW Government will invest an additional $100 million in Stage 2.“This funding boost will help NSW Ambulance deliver the most contemporary, efficient can i get viagra over the counter at walmart new ambulance stations to support our paramedics as they continue to deliver high quality emergency medical care to rural and regional communities,” Mr Hazzard said.“The new ambulance station for Lake Cathie will be tailored to best meet the needs of the region, and will provide local paramedics with the optimal base to work from as they continue their vital job of helping community members in their hour of need.”NSW Ambulance Chief Executive Dr Dominic Morgan said the extra boost to regional services was a welcome announcement for staff and local communities.“It means our committed paramedics will be better equipped and positioned to do what they do best, help the people of NSW with top quality care when they need it most,” Dr Morgan said.<>/p>. Member for Port Macquarie Leslie Williams said the new ambulance station will be a welcome addition to the community of Lake Cathie.“The NSW Government’s commitment to ambulance can i get viagra over the counter at walmart infrastructure will support the key growth areas of Lake Cathie and Bonny Hills,” Mrs Williams said. The initial RAIR program received $122 million, the single largest investment in regional NSW Ambulance’s 125-year history, with 24 communities across the state benefitting from an upgraded, rebuilt or entirely new ambulance station.“This program has already proved an enormous success and NSW Ambulance will continue its promise to deliver the most up to date equipment and facilities to keep our communities and ambulance staff as safe as possible,” Mr Hazzard said.The 2019-20 Budget for NSW Ambulance was more than $1 billion which included $27.1 million to employ an additional 221 paramedics and control centre staff to improve response times, reduce paramedic fatigue and support safety.Residents in the Camden Haven area will benefit from a new HealthOne facility in Laurieton which will provide a one stop shop for healthcare services.Health Minister Brad Hazzard and Member for Port Macquarie Leslie Williams today announced the new HealthOne facility would be built in Laurieton under the NSW Government’s $100 million HealthOne Program, delivering integrated healthcare to the local community.Mr Hazzard said the NSW Government’s HealthOne centres were making a can i get viagra over the counter at walmart big difference to communities across the state, providing essential healthcare services together in the one hub for ease and convenience, to boost health outcomes.“Bringing health services together under the one roof, closer to home, makes it easier for the community to access a range of health professionals to meet their varying healthcare needs,” Mr Hazzard said.“The new HealthOne will provide additional healthcare services for the whole Camden Haven community, so residents won’t have to travel to larger centres to address many of their healthcare needs.”Mrs Williams said the HealthOne would deliver an expanded range of health services, building on the community and allied health services already provided locally.“HealthOne centres aim to create a stronger and more efficient primary healthcare system by bringing general practice and a range of community healthcare services together as a ‘one stop shop’,” Mrs Williams said.“Local staff are excited about this new health facility and have been involved in its planning every step of the way.”Services to be provided include:oral healthchronic disease managementallied health servicesaged care serviceschild and family health servicesmental health and drug and alcohol services.Construction of the new Camden Haven HealthOne is due to begin in early 2021 and is expected to be operational by end of the year.The Mid North Coast Local Health District already has two HealthOne projects underway at Bowraville and Nambucca Heads.The Bowraville community is eagerly awaiting the completion of construction of their new centre in High Street while Nambucca HealthOne, which opened in 2015 is being expanded to provide additional health services for the community.The NSW Government has committed $10.1 billion in health infrastructure investment in the four years to 2023, including more than $900 million for rural and regional areas in 2019-20..

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User Experience (UX) Design is the process of enhancing a persons experience with a given product, system or service. UX involves an in depth understanding of a users behaviors, attitudes, and emotions in order to create a successful design.
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