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Moving faster to end preventable buy lasix overnight delivery newborn deaths and stillbirths by 2030Global actions now will determine the course of maternal and newborn visit homepage health for the next decade and the health and lives of future generations. Essential health services, including high-quality maternal and newborn buy lasix overnight delivery health care must be sustained and further strengthened to withstand shocks like hypertension medications, in order to protect the lives and health of women and children and make progress towards the SDGs. Countries and partners will discuss how to meet these targets and milestones. The actions needed at country level, the challenges faced and the buy lasix overnight delivery support required from regional and global partners.DATE.
SEPTEMBER 3 2020TIME. 14:00 - buy lasix overnight delivery 16:00 CETRegister in advance. Click here to register.WHO has been made aware of multiple, recent reports of eye injury, including blindness, with the use of chlorhexidine gluconate 7.1%, in nine countries in sub Saharan Africa.Chlorhexidine gluconate (CHX), available as an aqueous solution or as a gel (delivering 4% buy lasix overnight delivery chlorhexidine), is used in umbilical cord care, and is listed in the WHO Essential Medicines List1. WHO recommends daily chlorhexidine (4%) application to the umbilical cord stump during the first week of life for newborns who are born at home in settings with high neonatal mortality (neonatal mortality rate >30 per 1000).
Clean, dry cord care is recommended for newborns buy lasix overnight delivery born in health facilities, and at home in low neonatal mortality settings. Use of chlorhexidine in these situations may be considered only to replace application of a harmful traditional substance such as cow dung to the cord stump. The use of buy lasix overnight delivery CHX is being implemented in many countries (South Asia and sub-Saharan Africa) as part of a package of essential newborn interventions to reduce the incidence of omphalitis2.CHX causes serious harm if mistakenly applied to the eyes, resulting in severe eye injuries. Over forty (40) cases of such incorrect administration are recorded, either buy lasix overnight delivery as media reports, or in the literature, since 2015.
Injuries associated with both the liquid and gel (ointment) formulations have been reported when CHX was mistaken for eye drops or ointments.The present Alert is being issued to warn all stakeholders involved in the umbilical cord care programmes about this potential misadministration and risk of serious injury with CHX. All healthcare professionals, caregivers and others involved in its distribution, use and/or administration are advised to take all necessary measures and precautions to ensure its correct use and administration.Suggestions to National Neonatal and Reproductive Health Programmes and/or Regulators include the following:Assess what products are part of the newborn package and select the optimal primary container/dosage form for CHX or modify the design of the container to distinguish the product from other medicines typically used for newborns.Update the product label with appropriate information on the safe use of the product.Develop more detailed instructions for users (flyers, posters, pictorials etc.) that are culturally appropriate and easy to understand, to ensure correct use of the product.Train health care professionals who interact with mothers and/or provide the product to ensure the full understanding of the indications and contraindications for use and application methods.All stakeholders are advised to remain alert to incidents of eye injury with CHX in their settings and to report these buy lasix overnight delivery to their National Regulatory Authority (NRA). Member States are reminded that adverse events associated with the use of any medicinal product should be reported to the National Regulatory Authority.For any questions relating to this alert please contact Dr S Pal (pals@who.int) or Dr J Simon (simonjo@who.int).FOOTNOTE:.
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A prisoner at the Bolivar County Correctional Facility receives a hypertension medications go to this web-site vaccination administered by medical workers with Delta Health Center on April 28, 2021 in Cleveland, Mississippi.Spencer lasix 40mg cost Platt | Getty ImagesMississippi Gov. Tate Reeves pleaded Friday with residents to get vaccinated as the state scrambles to hire hundreds of temporary lasix 40mg cost doctors, nurses and EMTs. He's also requested ventilators from the National Stockpile as the spread of lasix 40mg cost the delta variant fills hospitals in the state with mostly unvaccinated patients. The state even asked federal officials to send a medical U.S.
Navy ship, but was turned down, lasix 40mg cost he said. "When you look across the country, to a certain extent, this current wave is the lasix 40mg cost lasix of the unvaccinated," Reeves said at a press conference, adding that the state was headed toward a new peak of the hypertension medications lasix. "We continue lasix 40mg cost to see more and more data and the data is becoming more and more clear. Those who received the treatment are significantly less likely to contract the lasix." For the few breakthrough cases in fully vaccinated people the state has seen so far, "they're much less likely to spread the lasix and it is highly unlikely that if you have the treatment that you end up in the hospital, or that you end up in an ICU bed," he said.Mississippi extended a state of emergency order on Thursday that was set to expire this week after the state recorded a new record of more than 5,000 new hypertension medications cases in one day, said Reeves, who's Republican.
The spike in cases will likely be followed by an increase in hospitalizations and deaths.The state requested 65 physicians, 920 nurses, 41 nursing aides, 59 advanced lasix 40mg cost practice nurses, 34 physician assistants, 239 respiratory technicians and 20 EMTs, according to Reeves. The extra help would open up 771 medical surgery beds and 235 ICU beds, he said.About 97% of people currently hospitalized for hypertension medications in the lasix 40mg cost state are unvaccinated, a trend seen throughout the country. This week, the Mississippi's daily hospitalization rate reached numbers higher than any the state has seen throughout the lasix.In the last four days, "we've lost four healthy people in their 20s, two of whom were pregnant, zero vaccinated," Mississippi lasix 40mg cost state health officer Dr. Thomas Dobbs said during the briefing.
"If we look at those who are in their 30s in the past four days, we've lost 10 people in their 30s and lasix 40mg cost these aren't people who are chronically ill cancer patients." None in their 30s who died were vaccinated.CNBC Health &. Science In other age groups, the number of deaths in unvaccinated people continued lasix 40mg cost to overwhelmingly eclipse the number of deaths in vaccinated people."I mean, there's a pattern here ... By and large the treatments have been incredibly protective and helpful and especially for people who are under 50," Dobbs said.The state has one of the lowest vaccination rates per capita in the United States, but daily vaccination rates have tripled over the past month amid the spread of the dominant delta variant, according to state health officials.The governor said he has no intention of mandating masks or treatments for state employees "or for anyone else," and emphasized that he believes those things are personal choices."I have no intention based upon the data that I have seen of issuing a statewide mask mandate," Reeves said in a press briefing on Friday.Reeves continued that he does not plan to impose mask mandates on schools either, saying that school districts "have every right" to encourage mask use if they deem it necessary.More than 5,000 children are currently quarantining after positive cases were detected in just the first couple of weeks of schools reopening, some without mask mandates.In total, Mississippi has recorded 381,147 hypertension medications cases and 7,761 deaths since the beginning of the lasix, according to the Mississippi State Department of Health..
A prisoner at the Bolivar County Correctional Facility receives a hypertension medications vaccination administered by medical workers with Delta Health Center on browse around here April 28, 2021 in Cleveland, Mississippi.Spencer buy lasix overnight delivery Platt | Getty ImagesMississippi Gov. Tate Reeves buy lasix overnight delivery pleaded Friday with residents to get vaccinated as the state scrambles to hire hundreds of temporary doctors, nurses and EMTs. He's also requested ventilators from the National Stockpile as the spread of the delta variant fills hospitals in the state buy lasix overnight delivery with mostly unvaccinated patients. The state even asked federal officials to send a medical U.S.
Navy ship, but was turned down, he said buy lasix overnight delivery. "When you look across the country, to a certain extent, this current wave is the lasix of the unvaccinated," Reeves buy lasix overnight delivery said at a press conference, adding that the state was headed toward a new peak of the hypertension medications lasix. "We continue buy lasix overnight delivery to see more and more data and the data is becoming more and more clear. Those who received the treatment are significantly less likely to contract the lasix." For the few breakthrough cases in fully vaccinated people the state has seen so far, "they're much less likely to spread the lasix and it is highly unlikely that if you have the treatment that you end up in the hospital, or that you end up in an ICU bed," he said.Mississippi extended a state of emergency order on Thursday that was set to expire this week after the state recorded a new record of more than 5,000 new hypertension medications cases in one day, said Reeves, who's Republican.
The spike in cases will likely buy lasix overnight delivery be followed by an increase in hospitalizations and deaths.The state requested 65 physicians, 920 nurses, 41 nursing aides, 59 advanced practice nurses, 34 physician assistants, 239 respiratory technicians and 20 EMTs, according to Reeves. The extra help would open up 771 medical surgery beds and 235 ICU beds, he said.About 97% of people currently hospitalized for hypertension medications buy lasix overnight delivery in the state are unvaccinated, a trend seen throughout the country. This week, the Mississippi's daily hospitalization rate reached numbers higher than any the state has seen throughout the lasix.In the last four days, "we've lost four healthy people in their 20s, two of whom were pregnant, zero vaccinated," Mississippi state buy lasix overnight delivery health officer Dr. Thomas Dobbs said during the briefing.
"If we look at those who are in their 30s in the past four days, we've lost 10 people in their 30s and these aren't people who are buy lasix overnight delivery chronically ill cancer patients." None in their 30s who died were vaccinated.CNBC Health &. Science In other age groups, the number of deaths in unvaccinated people continued to overwhelmingly eclipse the number of deaths buy lasix overnight delivery in vaccinated people."I mean, there's a pattern here ... By and large the treatments have been incredibly protective and helpful and especially for people who are under 50," Dobbs said.The state has one of the lowest vaccination rates per capita in the United States, but daily vaccination rates have tripled over the past month amid the spread of the dominant delta variant, according to state health officials.The governor said he has no intention of mandating masks or treatments for state employees "or for anyone else," and emphasized that he believes those things are personal choices."I have no intention based upon the data that I have seen of issuing a statewide mask mandate," Reeves said in a press briefing on Friday.Reeves continued that he does not plan to impose mask mandates on schools either, saying that school districts "have every right" to encourage mask use if they deem it necessary.More than 5,000 children are currently quarantining after positive cases were detected in just the first couple of weeks of schools reopening, some without mask mandates.In total, Mississippi has recorded 381,147 hypertension medications cases and 7,761 deaths since the beginning of the lasix, according to the Mississippi State Department of Health..
If you miss a dose, take it as soon as you can. If it is almost time for your next dose, take only that dose. Do not take double or extra doses.
Comfort and pain can lasix cause swelling management have always lasix 100mg price been paramount in the child-centered approach to care at UC Davis ChildrenâÂÂs Hospital. A new hospital initiative called Comfort Commitment launched this month, which provides a standardized approach to help pediatric patients better cope with distressing procedures and decrease can lasix cause swelling pain and anxiety. Child life specialist Emily McDaniel and nurse Carter Todd discuss comfort planning with a patient.It involves four steps to managing a patientâÂÂs comfort:Ask the child and caregiver what they know and understand about the procedureShare more about the procedure in simple terms using honest, age-appropriate languagePlan for the procedure, considering medicine and numbing options, refocusing techniques (toys, electronics, music), comfort positions (chest-to-chest for small children with their caregiver, swaddle for infants and young toddlers) and a calming environment (with lights, noises and words)Follow the agreed-upon plan and ensure the child feels heard and modify comfort measures to meet the patientâÂÂs needsâÂÂOur ultimate goal is to establish an environment where hospital experiences can be growth-promoting for children and families,â said child life specialist Emily McDaniel. ÃÂÂThrough individualizing procedural comfort plans with this collaborative four-step process, we are consistently able to provide coping support and empower the child to customize a plan that uniquely can lasix cause swelling meets their specific needs.âÂÂThe initiative was funded by a Children's Miracle Network at UC Davis grant. For more information, visit https://ucdavis.health/comfort.A lasix is probably not the best time to refer to someoneâÂÂs personality as âÂÂinfectious.â Shalaine Reddic has always believed she could do more than people thought she could.But you donâÂÂt have to talk with Shalaine Reddic for long, even on the phone, to feel the positive energy and can-do spirit of this UC Davis Medical Center nurse.ReddicâÂÂs desire to help patients blends perfectly with her strong drive to succeed, academic muscle and never-say-die attitude â all wrapped up in what she calls her fashion-forward style.A single mother of three, Reddic has never stopped moving up the career ladder.
She started out doing clerical work on the can lasix cause swelling Davis campus years ago. Today, Reddic is on the verge of becoming a licensed nurse practitioner.âÂÂI always like to can lasix cause swelling stay busy,â said Reddic.ThatâÂÂs an understatement. She was deftly juggling the phone conversation after a long work week while providing cooking instruction to her 16-year-old son. ÃÂÂAnd IâÂÂve always believed that I could do more than people thought I could,â she said.When she first started working, the Rancho Cordova resident didnâÂÂt consider can lasix cause swelling the patient side of health care. She didnâÂÂt enjoy the thought of seeing blood or being in the clinic environment.
But after becoming a clinical quality improvement coordinator at UC Davis Health, she started working with nurses and quickly gained an appreciation for the profession.Reddic spent nearly 10 years slowly but steadily taking classes and moving from one nursing degree to the next â from an associate of artâÂÂs degree can lasix cause swelling at a community college to a bachelorâÂÂs degree (cum laude, of course) from Sacramento State â all while working and almost single-handedly raising her children.âÂÂI have seen her push through personal issues on numerous occasions,â said Darrell Desmond, nurse manager of ReddicâÂÂs hospital unit. ÃÂÂBut she just keeps moving forward with an always positive attitude despite lifeâÂÂs many challenges.âÂÂIt was while volunteering can lasix cause swelling at a community clinic for underserved women in Sacramento that Reddic had what she calls an epiphany. It was a moment of intense clarity for someone who already had a rewarding nursing career.âÂÂI saw nurse practitioners working with patients, diagnosing health problems, prescribing medications,â Reddic said. ÃÂÂThey were providers can lasix cause swelling. They had the autonomy to buy lasix 40mg online make patient-care decisions.
For me, can lasix cause swelling that was it. I was in tears because I knew then and there that was what I really wanted to do.âÂÂSo, Reddic decided to add another academic achievement to her three nursing degrees and an AA degree in business administration. A graduate degree as a family nurse practitioner.Always on the move, Reddic never stops seeking new goals can lasix cause swelling and achievements.Three years and many commute miles later, she recently completed her masterâÂÂs from Sonoma State and is now studying for her boards. While working full time, of course.Reddic admits to being overwhelmed at times over the can lasix cause swelling years. But she said strong faith and prayer helped her put things in perspective when she felt defeated and exhausted.âÂÂItâÂÂs been a journey and a learning process,â Reddic said.
ÃÂÂIâÂÂve got a few can lasix cause swelling bruises, but IâÂÂm still here and excited about each day. When I face adversity, I always step it up a notch.âÂÂAs if it wasnâÂÂt enough to become a nurse practitioner, Reddic is considering going back to school for a certificate in psychiatry and, perhaps, a doctorate at some point.SheâÂÂs also dreaming about plans for starting two independent clinics. One would be dedicated to can lasix cause swelling serving underprivileged communities. The other can lasix cause swelling would be an IV hydration bar, a trending intravenous therapy program for wellness, beauty and health.âÂÂShalaine has organized her life for success,â said Joleen Lonigan, an executive director of Patient Care Services at UC Davis Medical Center. ÃÂÂSheâÂÂs turned her motivation into achievements and her pathway into inspiration that can benefit others.âÂÂHer story is undoubtedly motivational for anyone who knows Reddic.
Colleagues say her determination is can lasix cause swelling impressive. Her attitude always stays positive, undoubtedly enhanced by that fashion-forward sensibility that can be seen, despite the required nursing apparel, in some colorful shoe choices and unique earrings. And those academic and can lasix cause swelling clinical accomplishments?. TheyâÂÂre likely just steppingstones leading toward further personal and professional goals.In short, Shalaine Reddic and the spirit with which she approaches life seem â even in a lasix age â wonderfully contagious..
Comfort and pain management have always been paramount in buy lasix with prescription the buy lasix overnight delivery child-centered approach to care at UC Davis ChildrenâÂÂs Hospital. A new hospital initiative called Comfort Commitment launched this month, which provides a standardized approach to help pediatric patients better cope with distressing buy lasix overnight delivery procedures and decrease pain and anxiety. Child life specialist Emily McDaniel and nurse Carter Todd discuss comfort planning with a patient.It involves four steps to managing a patientâÂÂs comfort:Ask the child and caregiver what they know and understand about the procedureShare more about the procedure in simple terms using honest, age-appropriate languagePlan for the procedure, considering medicine and numbing options, refocusing techniques (toys, electronics, music), comfort positions (chest-to-chest for small children with their caregiver, swaddle for infants and young toddlers) and a calming environment (with lights, noises and words)Follow the agreed-upon plan and ensure the child feels heard and modify comfort measures to meet the patientâÂÂs needsâÂÂOur ultimate goal is to establish an environment where hospital experiences can be growth-promoting for children and families,â said child life specialist Emily McDaniel. ÃÂÂThrough individualizing procedural comfort plans with this collaborative four-step process, we are consistently able to provide coping support and empower the child to customize a plan that uniquely meets their specific needs.âÂÂThe initiative was funded by a Children's Miracle Network at buy lasix overnight delivery UC Davis grant.
For more information, visit https://ucdavis.health/comfort.A lasix is probably not the best time to refer to someoneâÂÂs personality as âÂÂinfectious.â Shalaine Reddic has always believed she could do more than people thought she could.But you donâÂÂt have to talk with Shalaine Reddic for long, even on the phone, to feel the positive energy and can-do spirit of this UC Davis Medical Center nurse.ReddicâÂÂs desire to help patients blends perfectly with her strong drive to succeed, academic muscle and never-say-die attitude â all wrapped up in what she calls her fashion-forward style.A single mother of three, Reddic has never stopped moving up the career ladder. She started out doing clerical work on the buy lasix overnight delivery Davis campus years ago. Today, Reddic is on the verge of becoming a licensed nurse practitioner.âÂÂI always like buy lasix overnight delivery to stay busy,â said Reddic.ThatâÂÂs an understatement. She was deftly juggling the phone conversation after a long work week while providing cooking instruction to her 16-year-old son.
ÃÂÂAnd IâÂÂve always believed that I could do more than people thought I could,â buy lasix overnight delivery she said.When she first started working, the Rancho Cordova resident didnâÂÂt consider the patient side of health care. She didnâÂÂt enjoy the thought of seeing blood or being in the clinic environment. But after buy lasix overnight delivery becoming a clinical quality improvement coordinator at UC Davis Health, she started working with nurses and quickly gained an appreciation for the profession.Reddic spent nearly 10 years slowly but steadily taking classes and moving from one nursing degree to the next â from an associate of artâÂÂs degree at a community college to a bachelorâÂÂs degree (cum laude, of course) from Sacramento State â all while working and almost single-handedly raising her children.âÂÂI have seen her push through personal issues on numerous occasions,â said Darrell Desmond, nurse manager of ReddicâÂÂs hospital unit. ÃÂÂBut she just keeps moving forward with an always positive attitude despite lifeâÂÂs many challenges.âÂÂIt was while volunteering at a community clinic for underserved women in Sacramento that Reddic had what she calls an buy lasix overnight delivery epiphany.
It was a moment of intense clarity for someone who already had a rewarding nursing career.âÂÂI saw nurse practitioners working with patients, diagnosing health problems, prescribing medications,â Reddic said. ÃÂÂThey were providers buy lasix overnight delivery. They had the autonomy to make patient-care decisions. For me, that was it buy lasix overnight delivery.
I was in tears because I knew then and there that was what I really wanted to do.âÂÂSo, Reddic decided to add another academic achievement to her three nursing degrees and an AA degree in business administration. A graduate degree as a family nurse practitioner.Always on the move, Reddic never stops seeking new goals and achievements.Three years and many commute miles later, she recently completed her masterâÂÂs from Sonoma buy lasix overnight delivery State and is now studying for her boards. While working full time, of course.Reddic admits to buy lasix overnight delivery being overwhelmed at times over the years. But she said strong faith and prayer helped her put things in perspective when she felt defeated and exhausted.âÂÂItâÂÂs been a journey and a learning process,â Reddic said.
ÃÂÂIâÂÂve got a few bruises, but IâÂÂm still buy lasix overnight delivery here and excited about each day. When I face adversity, I always step it up a notch.âÂÂAs if it wasnâÂÂt enough to become a nurse practitioner, Reddic is considering going back to school for a certificate in psychiatry and, perhaps, a doctorate at some point.SheâÂÂs also dreaming about plans for starting two independent clinics. One would buy lasix overnight delivery be dedicated to serving underprivileged communities. The other would be an IV hydration bar, a trending intravenous therapy program for wellness, beauty and health.âÂÂShalaine has organized her life for success,â said Joleen Lonigan, an executive director of Patient Care Services at UC Davis buy lasix overnight delivery Medical Center.
ÃÂÂSheâÂÂs turned her motivation into achievements and her pathway into inspiration that can benefit others.âÂÂHer story is undoubtedly motivational for anyone who knows Reddic. Colleagues say her determination is impressive buy lasix overnight delivery. Her attitude always stays positive, undoubtedly enhanced by that fashion-forward sensibility that can be seen, despite the required nursing apparel, in some colorful shoe choices and unique earrings. And those academic and clinical accomplishments? buy lasix overnight delivery.
TheyâÂÂre likely just steppingstones leading toward further personal and professional goals.In short, Shalaine Reddic and the spirit with which she approaches life seem â even in a lasix age â wonderfully contagious..
See info here 1 2 1 2 3 1 2 Income $875 (up from $859 in 201) $1284 (up from $1,267 in 2019) $1,468 $1,983 $2,498 $2,127 $2,873 Resources $15,750 (up from $15,450 in 2019) $23,100 (up from $22,800 lasix 20mg dosage in 2019) NO LIMIT** NO LIMIT SOURCE http://www.techdarkside.com/best-price-levitra-20mg/ for 2019 figures is GIS 18 MA/015 - 2019 Medicaid Levels and Other Updates (PDF). All of the attachments with the various levels are posted here. NEED TO KNOW PAST MEDICAID INCOME AND RESOURCE LEVELS?. Which household size applies? lasix 20mg dosage.
The rules are complicated. See rules here. On the HRA Medicaid Levels chart - Boxes 1 and lasix 20mg dosage 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels. Box 10 on page 3 are the MAGI income levels -- The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers.
People in the "MAGI" category - those NOT on Medicare -- have expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit. Box 3 on page 1 is Spousal lasix 20mg dosage Impoverishment levels for Managed Long Term Care &. Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school. 42 C.F.R.
ç 435.4 lasix 20mg dosage. Certain populations have an even higher income limit - 224% FPL for pregnant women and babies <. Age 1, 154% FPL for children age 1 - 19. CAUTION lasix 20mg dosage.
What is counted as income may not be what you think. For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline and these charts on income disregards. However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income lasix 20mg dosage will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI). There are good changes and bad changes.
GOOD. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as lasix 20mg dosage income. BAD. There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules.
For all of lasix 20mg dosage the rules see. ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits - with resource rules The income limits increase with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person. HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical. There are different rules depending on the "category" of lasix 20mg dosage the person seeking Medicaid.
Here are the 2 basic categories and the rules for calculating their household size. People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size. These same rules apply to the Medicare Savings Program, with some exceptions explained in lasix 20mg dosage this article. Everyone else -- MAGI - All children and adults under age 65, including people with disabilities who are not yet on Medicare -- this is the new "MAGI" population.
Their household size will be determined using federal income tax rules, which are very complicated. New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act lasix 20mg dosage (ACA) of 2010 (PDF) pp. 8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, including how to determine the Household Size. See slides 28-49.
Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI lasix 20mg dosage and reside with an applicant/recipient. Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the 1st "DAB" category. Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility. See 18 NYCRR 360-4.2, lasix 20mg dosage MRG p.
573, NYS GIS 2000 MA-007 CAUTION. Different people in the same household may be in different "categories" and hence have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's lasix 20mg dosage household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI. The following programs were available prior to 2014, but are now discontinued because they are folded into MAGI Medicaid.
Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under lasix 20mg dosage 21 in the household. It was sometimes known as "S/CC" category for Singles and Childless Couples. This category had lower income limits than DAB/ADC-related, but had no asset limits.
It did not allow "spend down" of lasix 20mg dosage excess income. This category has now been subsumed under the new MAGI adult group whose limit is now raised to 138% FPL. Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL. This has now been folded into the new MAGI adult group whose lasix 20mg dosage limit is 138% FPL.
For applicants between 138%-150% FPL, they will be eligible for a new program where Medicaid will subsidize their purchase of Qualified Health Plans on the Exchange. PAST INCOME &. RESOURCE LEVELS -- Past Medicaid lasix 20mg dosage income and resource levels in NYS are shown on these oldNYC HRA charts for 2001 through 2019, in chronological order. These include Medicaid levels for MAGI and non-MAGI populations, Child Health Plus, MBI-WPD, Medicare Savings Programs and other public health programs in NYS.
This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.A huge barrier to people returning to the community from nursing homes is the high cost of housing. One way New York State is trying to address that barrier is with the Special Housing Disregard that allows certain members of Managed Long Term Care or FIDA plans to keep more of their income to pay for rent or other shelter costs, rather than having to "spend down" their "excess income" or spend-down on lasix 20mg dosage the cost of Medicaid home care. The special income standard for housing expenses helps pay for housing expenses to help certain nursing home or adult home residents to safely transition back to the community with MLTC. Originally it was just for former nursing home residents but in 2014 it was expanded to include people who lived in adult homes.
GIS 14/MA-017 Since you are allowed to keep more of your income, you may no longer need to lasix 20mg dosage use a pooled trust. KNOW YOUR RIGHTS - FACT SHEET on THREE ways to Reduce Spend-down, including this Special Income Standard. September 2018 NEWS -- Those already enrolled in MLTC plans before they are admitted to a nursing home or adult home may obtain this budgeting upon discharge, if they meet the other criteria below. "How nursing home administrators, adult home operators lasix 20mg dosage and MLTC plans should identify individuals who are eligible for the special income standard" and explains their duties to identify eligible individuals, and the MLTC plan must notify the local DSS that the individual may qualify.
"Nursing home administrators, nursing home discharge planning staff, adult home operators and MLTC health plans are encouraged to identify individuals who may qualify for the special income standard, if they can be safely discharged back to the community from a nursing home and enroll in, or remain enrolled in, an MLTC plan. Once an individual has been accepted into an MLTC plan, the MLTC plan must notify the individual's local district of social services that the transition has occurred and that the individual may qualify for the special income standard. The special income standard will be effective upon enrollment into the MLTC plan, or, for nursing home lasix 20mg dosage residents already enrolled in an MLTC plan, the month of discharge to the community. Questions regarding the special income standard may be directed to DOH at 518-474-8887.
Who is eligible for this special income standard?. must be age 18+, must have been in a nursing lasix 20mg dosage home or an adult home for 30 days or more, must have had Medicaid pay toward the nursing home care, and must enroll in or REMAIN ENROLLED IN a Managed Long Term Care (MLTC) plan or FIDA plan upon leaving the nursing home or adult home must have a housing expense if married, spouse may not receive a "spousal impoverishment" allowance once the individual is enrolled in MLTC. How much is the allowance?. The rates vary by region and change yearly.
Region Counties Deduction (2020) Central Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence, Tioga, Tompkins $436 Long Island Nassau, Suffolk $1,361 NYC Bronx, Kings, Manhattan, Queens, Richmond $1,451 (up from 1,300 in 2019) Northeastern Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington $483 North Metropolitan Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester $930 Rochester Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates $444 Western Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming $386 Past rates published as follows, available on DOH website 2020 rates published in Attachment I to GIS 19 MA/12 â 2020 Medicaid Levels and Other Updates 2019 rates published in Attachment 1 to GIS 18/MA015 - 2019 Medicaid Levels and Other Updates 2018 rates published in GIS 17 MA/020 - 2018 Medicaid Levels and Other Updates. The guidance on how the standardized amount of the disregard is calculated is found in NYS DOH 12- ADM-05. 2017 rate -- GIS 16 MA/018 - 2016 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards Attachment 12016 rate -- GIS 15-MA/0212015 rate -- Were not posted by DOH but were updated in WMS.
2015 Central $382 Long Island $1,147 NYC $1,001 Northeastern $440 N. Metropolitan $791 Rochester $388 Western $336 2014 rate -- GIS-14-MA/017 HOW DOES IT WORK?. Here is a sample budget for a single person in NYC with Social Security income of $2,386/month paying a Medigap premium of $261/mo. Gross monthly income $2,575.50 DEDUCT Health insurance premiums (Medicare Part B) - 135.50 (Medigap) - 261.00 DEDUCT Unearned income disregard - 20 DEDUCT Shelter deduction (NYCâÂÂ2019) - 1,300 DEDUCT Income limit for single (2019) - 859 Excess income or Spend-down $0 WITH NO SPEND-DOWN, May NOT NEED POOLED TRUST!.
HOW TO OBTAIN THE HOUSING DISREGARD. When you are ready to leave the nursing home or adult home, or soon after you leave, you or your MLTC plan must request that your local Medicaid program change your Medicaid budget to give you the Housing Disregard. See September 2018 NYS DOH Medicaid Update that requires MLTC plan to help you ask for it. The procedures in NYC are explained in this Troubleshooting guide.
NYC Medicaid program prefers that your MLTC plan file the request, using Form MAP-3057E - Special income housing Expenses NH-MLTC.pdf and Form MAP-3047B - MLTC/NHED Cover Sheet Form MAP-259f (revised 7-31-18)(page 7 of PDF)(DIscharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GOVERNMENT DIRECTIVES (beginning with oldest). NYS DOH 12- ADM-05 - Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility who Enroll into the Managed Long Term Care (MLTC) Program Attachment II - OHIP-0057 - Notice of Intent to Change Medicaid Coverage, (Recipient Discharged from a Skilled Nursing Facility and Enrolled in a Managed Long Term Care Plan) Attachment III - Attachment III â OHIP-0058 - Notice of Intent to Change Medicaid Coverage, (Recipient Disenrolled from a Managed Long Term Care Plan, No Special Income Standard) MLTC Policy 13.02. MLTC Housing Disregard NYC HRA Medicaid Alert Special Income Standard for housing expenses NH-MLTC 2-9-2013.pdf 2018-07-28 HRA MICSA ALERT Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility and who Enroll into the MLTC Program - update on previous policy.
References Form MAP-259f (revised 7-31-18)(page 7 of PDF)(Discharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GIS 18 MA/012 - Special Income Standard for Housing Expenses for Certain Managed Long-Term Care Enrollees Who are Discharged from a Nursing Home issued Sept. 28, 2018 - this finally implements the most recent Special Terms &. Conditions of the CMS 1115 Waiver that governs the MLTC program, dated Jan.
19, 2017. The section on this income standard is at pages 26-27.
65, Does not have buy lasix overnight delivery Medicare)(OR has Medicare and has dependent child <. 18 or <. 19 in school) 138% FPL*** Children <.
5 and pregnant women have HIGHER LIMITS than shown buy lasix overnight delivery ESSENTIAL PLAN For MAGI-eligible people over MAGI income limit up to 200% FPL No long term care. See info here 1 2 1 2 3 1 2 Income $875 (up from $859 in 201) $1284 (up from $1,267 in 2019) $1,468 $1,983 $2,498 $2,127 $2,873 Resources $15,750 (up from $15,450 in 2019) $23,100 (up from $22,800 in 2019) NO LIMIT** NO LIMIT SOURCE for 2019 figures is GIS 18 MA/015 - 2019 Medicaid Levels and Other Updates (PDF). All of the attachments with the various levels are posted here.
NEED TO KNOW buy lasix overnight delivery PAST MEDICAID INCOME AND RESOURCE LEVELS?. Which household size applies?. The rules are complicated.
See buy lasix overnight delivery rules here. On the HRA Medicaid Levels chart - Boxes 1 and 2 are NON-MAGI Income and Resource levels -- Age 65+, Blind or Disabled and other adults who need to use "spend-down" because they are over the MAGI income levels. Box 10 on page 3 are the MAGI income levels -- The Affordable Care Act changed the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers.
People in the "MAGI" category - those NOT on Medicare -- have buy lasix overnight delivery expanded eligibility up to 138% of the Federal Poverty Line, so may now qualify for Medicaid even if they were not eligible before, or may now be eligible for Medicaid without a "spend-down." They have NO resource limit. Box 3 on page 1 is Spousal Impoverishment levels for Managed Long Term Care &. Nursing Homes and Box 8 has the Transfer Penalty rates for nursing home eligibility Box 4 has Medicaid Buy-In for Working People with Disabilities Under Age 65 (still 2017 levels til April 2018) Box 6 are Medicare Savings Program levels (will be updated in April 2018) MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare, AND can also apply to adults with Medicare if they have a dependent child/relative under age 18 or under 19 if in school.
42 C.F.R buy lasix overnight delivery. ç 435.4. Certain populations have an even higher income limit - 224% FPL for pregnant women and babies <.
Age 1, 154% FPL for children age buy lasix overnight delivery 1 - 19. CAUTION. What is counted as income may not be what you think.
For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline and these charts buy lasix overnight delivery on income disregards. However, for the MAGI population - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI). There are good changes and bad changes.
GOOD buy lasix overnight delivery. Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income. BAD.
There is no more "spousal" or parental refusal for this population buy lasix overnight delivery (but there still is for the Disabled/Aged/Blind.) and some other rules. For all of the rules see. ALSO SEE 2018 Manual on Lump Sums and Impact on Public Benefits - with resource rules The income limits increase with the "household size." In other words, the income limit for a family of 5 may be higher than the income limit for a single person.
HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even buy lasix overnight delivery logical. There are different rules depending on the "category" of the person seeking Medicaid. Here are the 2 basic categories and the rules for calculating their household size.
People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart buy lasix overnight delivery for their household size. These same rules apply to the Medicare Savings Program, with some exceptions explained in this article. Everyone else -- MAGI - All children and adults under age 65, including people with disabilities who are not yet on Medicare -- this is the new "MAGI" population.
Their household size will be determined using federal income tax rules, which buy lasix overnight delivery are very complicated. New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010 (PDF) pp. 8-10 of the PDF, This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, including how to determine the Household Size.
See buy lasix overnight delivery slides 28-49. Also seeLegal Aid Society and Empire Justice Center materials OLD RULE used until end of 2013 -- Count the person(s) applying for Medicaid who live together, plus any of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient. Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21 (though if the child is disabled, use the rule in the 1st "DAB" category.
Under this rule, a child may be excluded from the household if that buy lasix overnight delivery child's income causes other family members to lose Medicaid eligibility. See 18 NYCRR 360-4.2, MRG p. 573, NYS GIS 2000 MA-007 CAUTION.
Different people in the same household may be in different "categories" and hence buy lasix overnight delivery have different household sizes AND Medicaid income and resource limits. If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI. The following programs were available prior to 2014, but are now discontinued because they are folded into MAGI Medicaid.
Prenatal Care Assistance Program (PCAP) was Medicaid for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for buy lasix overnight delivery pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL). Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household. It was sometimes known as "S/CC" category for Singles and Childless Couples.
This category had lower income limits than buy lasix overnight delivery DAB/ADC-related, but had no asset limits. It did not allow "spend down" of excess income. This category has now been subsumed under the new MAGI adult group whose limit is now raised to 138% FPL.
Family Health Plus - this was an expansion of Medicaid to families with income up to 150% buy lasix overnight delivery FPL and for childless adults up to 100% FPL. This has now been folded into the new MAGI adult group whose limit is 138% FPL. For applicants between 138%-150% FPL, they will be eligible for a new program where Medicaid will subsidize their purchase of Qualified Health Plans on the Exchange.
PAST INCOME & buy lasix overnight delivery. RESOURCE LEVELS -- Past Medicaid income and resource levels in NYS are shown on these oldNYC HRA charts for 2001 through 2019, in chronological order. These include Medicaid levels for MAGI and non-MAGI populations, Child Health Plus, MBI-WPD, Medicare Savings Programs and other public health programs in NYS.
This article was authored by the Evelyn Frank buy lasix overnight delivery Legal Resources Program of New York Legal Assistance Group.A huge barrier to people returning to the community from nursing homes is the high cost of housing. One way New York State is trying to address that barrier is with the Special Housing Disregard that allows certain members of Managed Long Term Care or FIDA plans to keep more of their income to pay for rent or other shelter costs, rather than having to "spend down" their "excess income" or spend-down on the cost of Medicaid home care. The special income standard for housing expenses helps pay for housing expenses to help certain nursing home or adult home residents to safely transition back to the community with MLTC.
Originally it was just for former nursing home residents but in 2014 it was expanded buy lasix overnight delivery to include people who lived in adult homes. GIS 14/MA-017 Since you are allowed to keep more of your income, you may no longer need to use a pooled trust. KNOW YOUR RIGHTS - FACT SHEET on THREE ways to Reduce Spend-down, including this Special Income Standard.
September 2018 NEWS -- Those already enrolled in MLTC plans before buy lasix overnight delivery they are admitted to a nursing home or adult home may obtain this budgeting upon discharge, if they meet the other criteria below. "How nursing home administrators, adult home operators and MLTC plans should identify individuals who are eligible for the special income standard" and explains their duties to identify eligible individuals, and the MLTC plan must notify the local DSS that the individual may qualify. "Nursing home administrators, nursing home discharge planning staff, adult home operators and MLTC health plans are encouraged to identify individuals who may qualify for the special income standard, if they can be safely discharged back to the community from a nursing home and enroll in, or remain enrolled in, an MLTC plan.
Once an buy lasix overnight delivery individual has been accepted into an MLTC plan, the MLTC plan must notify the individual's local district of social services that the transition has occurred and that the individual may qualify for the special income standard. The special income standard will be effective upon enrollment into the MLTC plan, or, for nursing home residents already enrolled in an MLTC plan, the month of discharge to the community. Questions regarding the special income standard may be directed to DOH at 518-474-8887.
Who is eligible buy lasix overnight delivery for this special income standard?. must be age 18+, must have been in a nursing home or an adult home for 30 days or more, must have had Medicaid pay toward the nursing home care, and must enroll in or REMAIN ENROLLED IN a Managed Long Term Care (MLTC) plan or FIDA plan upon leaving the nursing home or adult home must have a housing expense if married, spouse may not receive a "spousal impoverishment" allowance once the individual is enrolled in MLTC. How much is the allowance?.
The rates vary by region and change yearly. Region Counties Deduction (2020) Central Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence, Tioga, Tompkins $436 Long Island Nassau, Suffolk $1,361 NYC Bronx, Kings, Manhattan, Queens, Richmond $1,451 (up from 1,300 in 2019) Northeastern Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington $483 North Metropolitan Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester $930 Rochester Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates $444 Western Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming $386 Past rates published as follows, available on DOH website 2020 rates published in Attachment I to GIS 19 MA/12 â 2020 Medicaid Levels and Other Updates 2019 rates published in Attachment 1 to GIS 18/MA015 - 2019 Medicaid Levels and Other Updates 2018 rates published in GIS 17 MA/020 - 2018 Medicaid Levels and Other Updates.
The guidance on how the standardized amount of the disregard is calculated is found in NYS DOH 12- ADM-05. 2017 rate -- GIS 16 MA/018 - 2016 Medicaid Only Income and Resource Levels and Spousal Impoverishment Standards Attachment 12016 rate -- GIS 15-MA/0212015 rate -- Were not posted by DOH but were updated in WMS. 2015 Central $382 Long Island $1,147 NYC $1,001 Northeastern $440 N.
Metropolitan $791 Rochester $388 Western $336 2014 rate -- GIS-14-MA/017 HOW DOES IT WORK?. Here is a sample budget for a single person in NYC with Social Security income of $2,386/month paying a Medigap premium of $261/mo. Gross monthly income $2,575.50 DEDUCT Health insurance premiums (Medicare Part B) - 135.50 (Medigap) - 261.00 DEDUCT Unearned income disregard - 20 DEDUCT Shelter deduction (NYCâÂÂ2019) - 1,300 DEDUCT Income limit for single (2019) - 859 Excess income or Spend-down $0 WITH NO SPEND-DOWN, May NOT NEED POOLED TRUST!.
HOW TO OBTAIN THE HOUSING DISREGARD. When you are ready to leave the nursing home or adult home, or soon after you leave, you or your MLTC plan must request that your local Medicaid program change your Medicaid budget to give you the Housing Disregard. See September 2018 NYS DOH Medicaid Update that requires MLTC plan to help you ask for it.
The procedures in NYC are explained in this Troubleshooting guide. NYC Medicaid program prefers that your MLTC plan file the request, using Form MAP-3057E - Special income housing Expenses NH-MLTC.pdf and Form MAP-3047B - MLTC/NHED Cover Sheet Form MAP-259f (revised 7-31-18)(page 7 of PDF)(DIscharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard. GOVERNMENT DIRECTIVES (beginning with oldest).
NYS DOH 12- ADM-05 - Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility who Enroll into the Managed Long Term Care (MLTC) Program Attachment II - OHIP-0057 - Notice of Intent to Change Medicaid Coverage, (Recipient Discharged from a Skilled Nursing Facility and Enrolled in a Managed Long Term Care Plan) Attachment III - Attachment III â OHIP-0058 - Notice of Intent to Change Medicaid Coverage, (Recipient Disenrolled from a Managed Long Term Care Plan, No Special Income Standard) MLTC Policy 13.02. MLTC Housing Disregard NYC HRA Medicaid Alert Special Income Standard for housing expenses NH-MLTC 2-9-2013.pdf 2018-07-28 HRA MICSA ALERT Special Income Standard for Housing Expenses for Individuals Discharged from a Nursing Facility and who Enroll into the MLTC Program - update on previous policy. References Form MAP-259f (revised 7-31-18)(page 7 of PDF)(Discharge Notice) - NH must file with HRA upon discharge, certifying resident was informed of availability of this disregard.
GIS 18 MA/012 - Special Income Standard for Housing Expenses for Certain Managed Long-Term Care Enrollees Who are Discharged from a Nursing Home issued Sept.
One of the lasix 20mg tablets side effects priority actions in the New Zealand Healthy Ageing Strategy (2016) was to improve models of care for Home and community Support Services (HCSS) in response to the multiple how much does lasix medication cost and growing demands on HCSS. The National Framework for HCSS provides guidance for district health boards for future commissioning, developing, delivering and evaluating HCSS to improve national consistency and quality of care. The National Framework for HCSS lasix 20mg tablets side effects was developed in collaboration with key stakeholders in the HCSS sector, including older people and their whÃÂnau. It includes. a vision and principles to guide service design core (essential) components of services that could be expected anywhere in the country a draft outcomes framework describing the outcomes sought from HCSS at individual, population and system levels.
The National Framework for HCSS lasix 20mg tablets side effects covers DHB-funded services for. people aged 65 years and over who have an assessed need in response to an interRAI assessment and meet criteria for funding people considered to be alike in age and interest â for example, Pacific peoples and MÃÂori, aged over 55 years, and others aged over 60 years, with age-related disabilities older people receiving HCSS who require increased support following an acute health episode who have required hospitalisation HCSS that may continue concurrently with short-term Accident Compensation Corporation (ACC) services. Three additional initiatives are linked with developing the National Framework to help achieve consistency in service commissioning, provision and resource allocation. First, a National Service Specification for lasix 20mg tablets side effects HCSS. This service specification will become the nationally mandated specification describing in detail the services and service approaches required of DHBs and providers.
This National Service Specification will be implemented by July 2022, in line with DHB service commissioning timetables. This approach aims to achieve the best balance between national consistency and flexibility for DHBs in meeting the needs of their populations lasix 20mg tablets side effects. Second, a nationally consistent case-mix methodology will be developed for all DHBs to use as a way of improving targeting of resources according to need. Some DHBs are already applying case-mix methods to resource allocation or use. However, different versions of the methodology are being used, resulting in some lasix 20mg tablets side effects inconsistency in resource allocation and lack of transparency across DHBs.
This indicates the need for a single, nationally consistent case-mix method which will also be implemented across all DHBs by July 2022. Third, a nationally consistent outcomes and measurement framework will be developed for use in HCSS and is expected to be completed by July 2021.The Historical mortality web tool presents mortality data (numbers and age-standardised rates) by sex for certain causes of death from 1948 to 2016. Mortality data lasix 20mg tablets side effects by sex, age group and ethnicity (MÃÂori and non-MÃÂori) is presented from 1996 to 2016.The web how do i get lasix tool enables you to explore trends over time using interactive graphs and tables. Filtered results and the full data set can be downloaded from within the web tool. The causes of death included are.
All cancer Ischaemic heart disease Cerebrovascular disease Chronic lower respiratory diseases Other forms of heart disease Influenza and Pneumonia Diabetes lasix 20mg tablets side effects mellitus Motor vehicle accidents Intentional self-harm Assault All deaths. The full data set presented in the web tool is available for you to download in text file format. A technical document accompanies the web tool. This document contains information about the data source and analytical methods used to produce summary data, lasix 20mg tablets side effects and a data dictionary for variables used in the web tool. About the data used in this edition Data from 1948 to 1995 presented in these tables was sourced from publications in the Ministry of Health Mortality data and stats series.
Data from 1996 to 2016 was extracted from the New Zealand Mortality Collection records on 07 June 2019. At the time lasix 20mg tablets side effects of extraction, there were 606,450 deaths registered from 1996 to 2016. Included in this data were 641 deaths provisionally coded awaiting coronersâ findings and 41 deaths awaiting coronersâ findings with no known cause. Ethnic breakdowns of mortality data are only shown from 1996 onwards because there was a significant change in the way ethnicity was defined, and in the way ethnicity data was collected in 1995. For more information please refer to the Ministry of Health report, Mortality and lasix 20mg tablets side effects Demographic Data 1996.
Disclaimer In this edition, data for causes of death was extracted and recalculated for the years 1996âÂÂ2016 to reflect ongoing updates to data in the New Zealand Mortality Collection (for example, following the release of coronersâ findings) and the revision of population estimates and projections following each census. For this reason there may be small changes to some numbers and rates from those presented in previous publications and tables. We have lasix 20mg tablets side effects quality checked the collection, extraction, and reporting of the data presented here. However errors can occur. Contact the Ministry of Health if you have any concerns regarding any of the data or analyses presented here, at data-enquires@health.govt.nz.
One of the priority actions in the New Zealand Healthy Ageing Strategy (2016) was to lasix 40mg cost improve models of care for Home and community Support Services (HCSS) in response to the buy lasix overnight delivery multiple and growing demands on HCSS. The National Framework for HCSS provides guidance for district health boards for future commissioning, developing, delivering and evaluating HCSS to improve national consistency and quality of care. The National Framework for HCSS buy lasix overnight delivery was developed in collaboration with key stakeholders in the HCSS sector, including older people and their whÃÂnau. It includes. a vision and principles to guide service design core (essential) components of services that could be expected anywhere in the country a draft outcomes framework describing the outcomes sought from HCSS at individual, population and system levels.
The National Framework for HCSS covers DHB-funded buy lasix overnight delivery services for. people aged 65 years and over who have an assessed need in response to an interRAI assessment and meet criteria for funding people considered to be alike in age and interest â for example, Pacific peoples and MÃÂori, aged over 55 years, and others aged over 60 years, with age-related disabilities older people receiving HCSS who require increased support following an acute health episode who have required hospitalisation HCSS that may continue concurrently with short-term Accident Compensation Corporation (ACC) services. Three additional initiatives are linked with developing the National Framework to help achieve consistency in service commissioning, provision and resource allocation. First, a National buy lasix overnight delivery Service Specification for HCSS. This service specification will become the nationally mandated specification describing in detail the services and service approaches required of DHBs and providers.
This National Service Specification will be implemented by July 2022, in line with DHB service commissioning timetables. This approach aims to achieve the best balance between national consistency and flexibility for DHBs in meeting buy lasix overnight delivery the needs of their populations. Second, a nationally consistent case-mix methodology will be developed for all DHBs to use as a way of improving targeting of resources according to need. Some DHBs are already applying case-mix methods to resource allocation or use. However, different versions of the methodology are being used, resulting in some inconsistency in buy lasix overnight delivery resource allocation and lack of transparency across DHBs.
This indicates the need for a single, nationally consistent case-mix method which will also be implemented across all DHBs by July 2022. Third, a nationally consistent outcomes and measurement framework will be developed for use in HCSS and is expected to be completed by July 2021.The Historical mortality web tool presents mortality data (numbers and age-standardised rates) by sex for certain causes of death from 1948 to 2016. Mortality data by sex, age group and ethnicity http://peddaborowski.com/gender-tales/ (MÃÂori and non-MÃÂori) is buy lasix overnight delivery presented from 1996 to 2016.The web tool enables you to explore trends over time using interactive graphs and tables. Filtered results and the full data set can be downloaded from within the web tool. The causes of death included are.
All cancer Ischaemic heart disease Cerebrovascular disease Chronic lower respiratory diseases Other forms of heart disease Influenza and Pneumonia Diabetes mellitus Motor vehicle accidents buy lasix overnight delivery Intentional self-harm Assault All deaths. The full data set presented in the web tool is available for you to download in text file format. A technical document accompanies the web tool. This document contains information about the data source and analytical methods used to produce summary data, and a data dictionary for variables used in the web buy lasix overnight delivery tool. About the data used in this edition Data from 1948 to 1995 presented in these tables was sourced from publications in the Ministry of Health Mortality data and stats series.
Data from 1996 to 2016 was extracted from the New Zealand Mortality Collection records on 07 June 2019. At the time of extraction, there buy lasix overnight delivery were 606,450 deaths registered from 1996 to 2016. Included in this data were 641 deaths provisionally coded awaiting coronersâ findings and 41 deaths awaiting coronersâ findings with no known cause. Ethnic breakdowns of mortality data are only shown from 1996 onwards because there was a significant change in the way ethnicity was defined, and in the way ethnicity data was collected in 1995. For more information please refer buy lasix overnight delivery to the Ministry of Health report, Mortality and Demographic Data 1996.
Disclaimer In this edition, data for causes of death was extracted and recalculated for the years 1996âÂÂ2016 to reflect ongoing updates to data in the New Zealand Mortality Collection (for example, following the release of coronersâ findings) and the revision of population estimates and projections following each census. For this reason there may be small changes to some numbers and rates from those presented in previous publications and tables. We have buy lasix overnight delivery quality checked the collection, extraction, and reporting of the data presented here. However errors can occur. Contact the Ministry of Health if you have any concerns regarding any of the data or analyses presented here, at data-enquires@health.govt.nz.
How to cite this article:Singh OP how to buy cheap lasix. Comprehensive Mental Health Action Plan 2013âÂÂ2030. We must how to buy cheap lasix rise to the challenge. Indian J Psychiatry 2021;63:415-7In May 2013, WHO's Mental Health Action Plan 2013-2020 was adopted at the 66th World Health Assembly which was extended until 2030 by the 72nd World Health Assembly in May 2019 with modifications of some of the objectives and goal targets to ensure its alignment with the 2030 Agenda for Sustainable Development.
Further, in September 2021, the 74th World Health Assembly accepted the updates to the action plan, including updates to the target options for indicators and implementation how to buy cheap lasix. 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 how to buy cheap lasix community to implement things that we always have been talking about like:Global target 2.2 â Target's doubling of community-based mental health facilities by 2030 in 80% of countries. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 â Integration of mental health care into primary healthcareGlobal target 3.2 â Reduction in suicide rate by one-third by 2030Global target 3.3 â Psychological care for disasterGlobal target 4.2 â Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing.
It is an opportunity for us to expand how to buy cheap lasix psychiatry by being involved in general medical care and reduce stigma. We must also utilize this opportunity to press for the greater representation of psychiatry in MBBS curriculum throughout the country and stop not till it gets a separate subject status in undergraduate medical studies.Now is the time for us to strive to achieve all the objectives which provide an opportunity to expand mental health care, reduce stigma, and translate all the talk of furthering the growth of mental health into action.[2] References 1.World Health Organization. Mental Health Action Plan how to buy cheap lasix 2013-2020. Geneva.
World Health how to buy cheap lasix Organization. 2013. 2.World how to buy cheap lasix Health Organization. Comprehensive Mental Health Action Plan 2013-2030.
Geneva. World Health Organization. 2021. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.
AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_811_21 Tables [Table 1]Abstract Background.
Empathy plays a role not only in pathophysiology but also in planning management strategies for alcohol dependence. However, few studies have looked into it. No data are available regarding the variation of empathy with abstinence and motivation. Assessment based on cognitive and affective dimensions of empathy is needed.Aim.
This study aimed to assess cognitive and affective empathy in men with alcohol dependence and compared it with normal controls. Association of empathy with disease-specific variables, motivation, and abstinence was also done.Methods. This was a cross-sectional observational study conducted in the outpatient department of a tertiary care center. Sixty men with alcohol dependence and 60 healthy controls were recruited and assessed using the Basic Empathy Scale for cognitive and affective empathy.
The University of Rhode Island Change Assessment Scale was used to assess motivation. Other variables were assessed using a semi-structured pro forma. Comparative analysis was done using unpaired t-test and one-way ANOVA. Correlation was done using Pearson's correlation test.Results.
Cases with alcohol dependence showed lower levels of cognitive, affective, and total empathy as compared to controls. Affective and total empathy were higher in abstinent men. Empathy varied across various stages of motivation, with a significant difference seen between precontemplation and action stages. Empathy correlated negatively with number of relapses and positively with family history of addiction.Conclusions.
Empathy (both cognitive and affective) is significantly reduced in alcohol dependence. Higher empathy correlates with lesser relapses. Abstinence and progression in motivation cycle is associated with remission in empathic deficits.Keywords. Abstinence, alcohol, empathy, motivationHow to cite this article:Nachane HB, Nadadgalli GV, Umate MS.
Cognitive and affective empathy in men with alcohol dependence. Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry 2021;63:418-23How to cite this URL:Nachane HB, Nadadgalli GV, Umate MS. Cognitive and affective empathy in men with alcohol dependence.
Relation with clinical profile, abstinence, and motivation. Indian J Psychiatry [serial online] 2021 [cited 2021 Nov 4];63:418-23. Available from. Https://www.indianjpsychiatry.org/text.asp?.
2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement â such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components â cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking. It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence. This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare.
The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.
Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019âÂÂAugust 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18âÂÂ65 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 20âÂÂ30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale.
We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement). The subscales can be combined arithmetically (C + A + M â PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment.
Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY. IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables.
Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (÷p2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant.
Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis. The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated.
Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families. None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1].
The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. [Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = âÂÂ0.42, P = 0.001), followed by TE (r = âÂÂ0.39, P = 0.002) and least with AE (r = âÂÂ0.31, 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 mildâÂÂmoderate.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]. 1.34âÂÂ8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI. 2.63âÂÂ14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09âÂÂ5.77], 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 (÷p2 = 0.15) as compared to total empathy (÷p2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2]. However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <. 0.05).Figure 1.
Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2. Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation. Data expressed as mean (standard deviation)Click here to viewTable 4.
Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls. This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al.
Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called âÂÂcognitive-affective dissociation of empathyâ in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient â cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this. Empathy is a key factor in motivation to help others and oneself when in distress.
This suggests a role for it in motivation to quit and treatment seeking. Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes.
Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial. It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair 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 âÂÂequally heritable.â However, more research in this area is needed.Our study was not without limitations.
Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed. We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation.
As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE. Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications. Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected.
Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management. Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution.
Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C. Alcohol dependence. A public health perspective.
Addiction 2002;97:633-45. 2.Willenbring ML. The past and future of research on treatment of alcohol dependence. Alcohol Res Health 2010;33:55-63.
3.DiClemente CC. Conceptual models and applied research. The ongoing contribution of the transtheoretical model. J Addict Nurs 2005;16:5-12.
4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I. Motivation for change and psychological distress in homeless substance abusers. J Subst Abuse Treat 2000;19:395-401. 5.Beckman LJ.
An attributional analysis of Alcoholics Anonymous. J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of âÂÂmotivation for changeâ in psychoanalytic treatment.
Int J Psychoanal 1972;53:51-9. 7.Miller WR. Motivation for treatment. A review with special emphasis on alcoholism.
Psychol Bull 1985;98:84-107. 8.Murphy PN, Bentall RP. Motivation to withdraw from heroin. A factor-analytic study.
Br J Addict 1992;87:245-50. 9.Maurage P, Grynberg D, 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 cite this buy lasix overnight delivery article:Singh OP. Comprehensive Mental Health Action Plan 2013âÂÂ2030. We must rise to the challenge buy lasix overnight delivery.
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 buy lasix overnight delivery 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 buy lasix overnight delivery and 2013-30Click here to viewAs it is obvious that there is an enormous opportunity for the psychiatric community to implement things that we always have been talking about like:Global target 2.2 â Target's doubling of community-based mental health facilities by 2030 in 80% of countries. It would be a substantial achievement for the psychiatric community for its implementation will lead to significant service to psychiatric patientsGlobal target 2.3 â Integration of mental health care into primary healthcareGlobal target 3.2 â Reduction in suicide rate by one-third by 2030Global target 3.3 â Psychological care for disasterGlobal target 4.2 â Mental health research to be doubled by 2030.What has brought about profound change is target 3.4 of Sustainable Development Goal, which is to reduce premature death by NCD by one-third by promoting mental health and wellbeing. It is an opportunity for us to expand psychiatry by being involved in general buy lasix overnight delivery medical care and reduce stigma.
We must also utilize this opportunity to press for the greater representation of psychiatry in MBBS curriculum throughout the country and stop not till it gets a separate subject status in undergraduate medical studies.Now is the time for us to strive to achieve all the objectives which provide an opportunity to expand mental health care, reduce stigma, and translate all the talk of furthering the growth of mental health into action.[2] References 1.World Health Organization. Mental Health Action Plan 2013-2020 buy lasix overnight delivery. Geneva.
World Health Organization buy lasix overnight delivery. 2013. 2.World Health Organization buy lasix overnight delivery.
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 Nov 4];63:418-23. Available from.
Https://www.indianjpsychiatry.org/text.asp?. 2021/63/5/418/328088 Introduction Alcohol dependence is as much a social challenge as it is a clinical one.[1] Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence.[2] In substance abuse treatment, clients' motivation to change has often been the focus of both clinical interest and frustration.[3],[4] Motivation has been described as a prerequisite for treatment, without which the clinician can do little.[5] Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment.[6],[7] Treatment modalities have focused on various aspects of motivation enhancement â such as locus of control, social support, and networking.[8] Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence.[9] However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.[10]Broadly speaking, empathy is believed to be constituted of two components â cognitive and affective (or emotional).[9] Affective empathy (AE) deals with the ability of detecting and experiencing the others' emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind).[11] Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence.[9],[12] Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses.[9] However, research pertaining to empathy in alcohol has generated varied results.[9] Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects' empathy.[9],[13] However, few of these have assessed CE and AE separately.[9],[13] Previous literature has demonstrated that empathy correlates with the motivation to help others.[14] No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking.
It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence. This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare. The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls.
Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables. Materials and Methods The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center.
Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019âÂÂAugust 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18âÂÂ65 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 20âÂÂ30 min.InstrumentsThe Basic Empathy Scale for AdultsIt is a 20-item scale which was developed by Jolliffe and Farrington.[15] Each question is rated on a five point Likert type scale.
We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).The University of Rhode Island Change Assessment Scale (URICA)This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages. Precontemplation (PC), contemplation (C), action (A), and maintenance (M).[16] The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement).
The subscales can be combined arithmetically (C + A + M â PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment. Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)Statistical analysisSPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY.
IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables. Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate.
The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (÷p2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant.
Results A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis. The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married.
Only 58% of the cases and 57% of the controls were educated. Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families.
None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118) =2.59, P = 0.01), affective (t(118) =2.19, P = 0.03), and total empathy (t(118) =2.39, P = 0.02) to be significantly lower in cases [Table 1]. The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence.
[Table 2] shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = âÂÂ0.42, P = 0.001), followed by TE (r = âÂÂ0.39, P = 0.002) and least with AE (r = âÂÂ0.31, 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 mildâÂÂmoderate.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]. 1.34âÂÂ8.86], P = 0.009) and TE (t(58) =2.88, mean difference = 8.60 [95% CI.
2.63âÂÂ14.57], P = 0.006) as compared to those still consuming but not CE (t(58) =1.93, mean difference = 2.83 [95% CI. 0.09âÂÂ5.77], 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 (÷p2 = 0.15) as compared to total empathy (÷p2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2]. However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P <.
0.05).Figure 1. Difference in cognitive, affective, and total empathy among dependent and abstinent subjects. Data expressed as mean (standard deviation)Click here to viewFigure 2.
Cognitive, affective, and total empathy in cases across precontemplation, contemplation, and action stages of motivation. Data expressed as mean (standard deviation)Click here to viewTable 4. Comparison of cognitive, affective and total empathy in individual stages of motivation using post hoc Bonferroni testClick here to view Discussion Role of empathy in addictive behaviors is a pivotal one.[17] The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls.
This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al.
Elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods.[18] Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called âÂÂcognitive-affective dissociation of empathyâ in alcoholics, which resulted in a changed AE, with relatively intact CE.[9],[17] However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects.[19] Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits.[19] In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics.[20] Hence, our primary finding is in keeping with this hypothesis.Empathy may relate to various aspects of the psychopathological process.[21] Disorders have also been classified based on which aspect of empathy is deficient â cognitive, affective, or general.[21] On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors.[21] Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy.[22],[23] Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.[18]Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder.[24] The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment.[13],[23] A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups.[13] A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized,[13] and our findings support this.
Empathy is a key factor in motivation to help others and oneself when in distress. This suggests a role for it in motivation to quit and treatment seeking. Yet still, few studies have made this assessment.
Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes. Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement.
Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial. It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.[9]It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair 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 âÂÂequally heritable.â However, more research in this area is needed.Our study was not without limitations. Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed.
We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation. As our study was a cross-sectional study, it was not possible.To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates.[28] While many risk factors for alcohol dependence are difficult if not impossible to change,[29] some components of empathy may be modifiable,[13] particularly AE.
Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications. Conclusions Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected.
Even though psychotherapeutic approaches have hitherto targeted therapist's empathy,[30] we suggest that a detailed understanding of patient's empathy is equally crucial in the management. Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy.
The present analysis is associational and causality inference should be done with caution. Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice.[13],[31] Adding to existing factors that have proved successful for abstinence,[32] focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Caetano R, Cunradi C.
Alcohol dependence. A public health perspective. Addiction 2002;97:633-45.
2.Willenbring ML. The past and future of research on treatment of alcohol dependence. Alcohol Res Health 2010;33:55-63.
3.DiClemente CC. Conceptual models and applied research. The ongoing contribution of the transtheoretical model.
J Addict Nurs 2005;16:5-12. 4.Velasquez MM, Crouch C, von Sternberg K, Grosdanis I. Motivation for change and psychological distress in homeless substance abusers.
J Subst Abuse Treat 2000;19:395-401. 5.Beckman LJ. An attributional analysis of Alcoholics Anonymous.
J Stud Alcohol 1980;41:714-26. 6.Appelbaum A. A critical re-examination of the concept of âÂÂmotivation for changeâ in psychoanalytic treatment.
Int J Psychoanal 1972;53:51-9. 7.Miller WR. Motivation for treatment.
A review with special emphasis on alcoholism. Psychol Bull 1985;98:84-107. 8.Murphy PN, Bentall RP.
Motivation to withdraw from heroin. A factor-analytic study. Br J Addict 1992;87:245-50.
9.Maurage P, Grynberg D, 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].