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Figure 1 Daily number of PED presentations (A) and PED presentations for domestic accidents (B) in Padova from 1 January to 20 April in 2019 and 2020.

The vertical line corresponds to 8 March. Trends were smoothed using a local regression. PED, paediatric emergency department.View this table:Table 1 Comparison of paediatric emergency department presentations and hospitalisations for domestic accidents, overall and by domestic accident category, during the hypertension medications outbreak lockdown and the corresponding period of the previous yearIn the same period the total number of children with confirmed hypertension medications seen at our PED was only eight. Of these, six were hospitalised, of whom three were younger than 6 months, only one needed supplemental oxygen and none needed intensive care.Our data show that the number and severity of PED presentations for domestic accidents has significantly increased during the lockdown period compared with the previous year.

We acknowledge our results are limited by the single-centre design and the low absolute numbers of study outcomes, with the possibility that small variations in numbers in each period could affect the effect size of our findings. However, we believe they are useful to raise awareness that domestic accidents are posing a higher threat to children’s health than hypertension medications. Home safety and injury prevention measures in the household environment must be reinforced at the community and emergency department level alongside control measures for this lasix.4.

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Receiving and does lasix affect potassium levels http://dasilvapinho.com/levitra-pill-price/ distributing treatments. For hard-to-access clinics, the lasix has brought on unique challenges -- from health care workers being forced to drive long distances to administer them, to a severe impact in distribution capabilities if there is even one positive hypertension medications test amongst medical staff.Source. CNN.

Go There heads to order lasix overnight delivery rural Montana and Texas, Click This Link where small clinics overwhelmed by the lasix prepare to face another challenge. Receiving and distributing treatments. For hard-to-access clinics, the lasix has brought on unique challenges -- from health care workers being forced to drive long distances to administer them, to a severe impact in distribution capabilities if there is even one positive hypertension medications test amongst medical staff.Source.

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Imaging the digoxin and lasix encephalopathy of prematurityJulia Kline and colleagues assessed MRI findings at term in 110 preterm infants born before 32 weeks’ gestation and cared for in four neonatal units in Columbus, Ohio. Using automated cortical and sub-cortical segmentation they analysed cortical surface area, sulcal depth, gyrification index, inner cortical curvature and thickness. These measures of brain development and maturation were related to the outcomes of cognitive and language testing undertaken at 2 years corrected age using the digoxin and lasix Bayley-III. Increased surface area in nearly every brain region was positively correlated with Bayley-III cognitive and language scores.

Increased inner cortical curvature was negatively correlated with both outcomes. Gyrification index and sulcal depth digoxin and lasix did not follow consistent trends. These metrics retained their significance after sex, gestational age, socio-economic status and global injury score on structural MRI were included in the analysis. Surface area and inner cortical curvature explained approximately one-third of the variance in Bayley-III scores.In an accompanying editorial, David Edwards characterises the complexity of imaging and interpreting the combined effects of injury and dysmaturation on the developing brain.

Major structural lesions are present in a minority of infants and digoxin and lasix the problems observed in later childhood require a much broader understanding of the effects of prematurity on brain development. Presently these more sophisticated image-analysis techniques provide insights at a population level but the variation between individuals is such that they are not sufficiently predictive at an individual patient level to be of practical use to parents or clinicians in prognostication. Studies like this highlight the importance of follow-up programmes and help clinicians to avoid falling into the trap of equating normal (no major structural lesion) imaging studies with normal long term outcomes. See pages F460 and F458Drift at 10 yearsKaren Luuyt and colleagues report the cognitive outcomes at digoxin and lasix 10 years of the DRIFT (drainage, irrigation and fibrinolytic therapy) randomised controlled trial of treatment for post haemorrhagic ventricular dilatation.

They are to be congratulated for continuing to track these children and confirming the persistence of the cognitive advantage of the treatment that was apparent from earlier follow-up. Infants who received DRIFT were almost twice as likely to survive without severe cognitive digoxin and lasix disability than those who received standard treatment. While the confidence intervals were wide, the point estimate suggests that the number needed to treat for DRIFT to prevent one death or one case of severe cognitive disability was 3. The original trial took place between 2003 and 2006 and was stopped early because of concerns about secondary intraventricular haemorrhage and it was only on follow-up that the advantages of the treatment became apparent.

The study shows that secondary brain injury digoxin and lasix can be reduced by washing away the harmful debris of IVH. No other treatment for post-haemorrhagic ventricular dilatation has been shown to be beneficial in a randomised controlled trial. Less invasive approaches to CSF drainage at different thresholds of ventricular enlargement later in the clinical course have not been associated with similar advantage. However the DRIFT treatment is complex and invasive and could only be provided digoxin and lasix in a small number of specialist referral centres and logistical challenges will need to be overcome to evaluate the treatment approach further.

See page F466Chest compressionsWith a stable infant in the neonatal unit, it is common to review the events of the initial stabilisation and to speculate on whether chest compressions were truly needed to establish an effective circulation, or whether their use reflected clinician uncertainty in the face of other challenges. Anne Marthe Boldinge and colleagues provide some objective data on the subject. They analysed videos that were recorded during neonatal stabilisation in a single centre with 5000 births per annum digoxin and lasix. From a birth population of almost 1200 infants there were good quality video recordings from 327 episodes of initial stabilisation where positive pressure ventilation was provided and 29 of these episodes included the provision of chest compressions, mostly in term infants.

6/29 of the infants who received chest compressions were retrospectively judged to have needed them. 8/29 had digoxin and lasix adequate spontaneous respiration. 18/29 received ineffective positive pressure ventilation prior to chest compressions. 5/29 had digoxin and lasix a heart rate greater than 60 beats per minute at the time of chest compressions.

A consistent pattern of ventilation corrective actions was not identified. One infant received chest compressions without prior heart rate assessment. See page 545Propofol for neonatal endotracheal intubationMost clinicians provide sedation/analgesia for neonatal intubations but there is still a digoxin and lasix lot of uncertainty about the best approach. Ellen de Kort and colleagues set out to identify the dose of propofol that would provide adequate sedation for neonatal intubation without side-effects.

They conducted a dose-finding trial which evaluated a range of doses in infants of different gestations. They ended digoxin and lasix their study after 91 infants because they only achieved adequate sedation without side effects in 13% of patients. Hypotension (mean blood pressure below post-mentrual age in the hour after treatment) was observed in 59% of patients. See page 489Growth to early adulthood following extremely preterm birthThe EPICure cohort comprised all babies born at 25 completed weeks of gestation or less in all 276 maternity units in the UK and Ireland from March to December 1995.

Growth data into adulthood are digoxin and lasix sparse for such immature infants. Yanyan Ni and colleagues report the growth to 19 years of 129 of the cohort in comparison with contemporary term born controls. The extremely preterm infants were on average 4.0 cm shorter and 6.8 kg lighter with a 1.5 cm smaller head circumference relative to controls at 19 digoxin and lasix years. Body mass index was significantly elevated to +0.32 SD.

With practice changing to include the provision of life sustaining treatment to greater numbers of infants born at 22 and 23 weeks of gestation there is a strong case for further cohort studies to include this population of infants. See page F496Premature birth is a worldwide problem, and digoxin and lasix the most significant cause of loss of disability-adjusted life years in children. Impairment and disability among survivors are common. Cerebral palsy is diagnosed in around 10% of infants born before 33 weeks of gestation, although the rates approximately double in the smallest and most vulnerable infants, and other motor disturbances are being detected in 25%–40%.

Cognitive, socialisation and behavioural problems are apparent digoxin and lasix in around half of preterm infants, and there is increased incidence of neuropsychiatric disorders, which develop as the children grow older. Adults born preterm are approximately seven times more likely to be diagnosed with bipolar disease.1 2The neuropathological basis for these long-term and debilitating disorders is often unclear. Brain imaging by ultrasound or MRI shows that only a relatively small proportion of infants have significant destructive brain lesions, and these major lesions are not detected commonly enough to account for the prevalence of long-term impairments. However, abnormalities of brain growth and maturation are common, and it is now apparent that, in addition to recognisable cerebral damage, adverse neurological, cognitive and psychiatric outcomes are consistently associated with digoxin and lasix abnormal cerebral maturation and development.Currently, most clinical decision-making remains focused around a number of well-described cerebral lesions usually detected in routine practice using cranial ultrasound.

Periventricular haemorrhage is common. Severe haemorrhages are associated with long-term adverse outcomes, and in infants born before 33 weeks of gestation, haemorrhagic parenchymal infarction predicts motor deficits ….

Imaging the encephalopathy of prematurityJulia Kline and colleagues assessed MRI findings at term in 110 preterm infants order lasix overnight delivery born before 32 weeks’ gestation and cared lasix uk buy for in four neonatal units in Columbus, Ohio. Using automated cortical and sub-cortical segmentation they analysed cortical surface area, sulcal depth, gyrification index, inner cortical curvature and thickness. These measures of brain development and maturation were related to the outcomes of order lasix overnight delivery cognitive and language testing undertaken at 2 years corrected age using the Bayley-III.

Increased surface area in nearly every brain region was positively correlated with Bayley-III cognitive and language scores. Increased inner cortical curvature was negatively correlated with both outcomes. Gyrification index and sulcal depth did not order lasix overnight delivery follow consistent trends.

These metrics retained their significance after sex, gestational age, socio-economic status and global injury score on structural MRI were included in the analysis. Surface area and inner cortical curvature explained approximately one-third of the variance in Bayley-III scores.In an accompanying editorial, David Edwards characterises the complexity of imaging and interpreting the combined effects of injury and dysmaturation on the developing brain. Major structural lesions are present in a minority of infants and the problems observed in later childhood require a much broader understanding of the order lasix overnight delivery effects of prematurity on brain development.

Presently these more sophisticated image-analysis techniques provide insights at a population level but the variation between individuals is such that they are not sufficiently predictive at an individual patient level to be of practical use to parents or clinicians in prognostication. Studies like this highlight the importance of follow-up programmes and help clinicians to avoid falling into the trap of equating normal (no major structural lesion) imaging studies with normal long term outcomes. See pages F460 and F458Drift at 10 yearsKaren order lasix overnight delivery Luuyt and colleagues report the cognitive outcomes at 10 years of the DRIFT (drainage, irrigation and fibrinolytic therapy) randomised controlled trial of treatment for post haemorrhagic ventricular dilatation.

They are to be congratulated for continuing to track these children and confirming the persistence of the cognitive advantage of the treatment that was apparent from earlier follow-up. Infants who order lasix overnight delivery received DRIFT were almost twice as likely to survive without severe cognitive disability than those who received standard treatment. While the confidence intervals were wide, the point estimate suggests that the number needed to treat for DRIFT to prevent one death or one case of severe cognitive disability was 3.

The original trial took place between 2003 and 2006 and was stopped early because of concerns about secondary intraventricular haemorrhage and it was only on follow-up that the advantages of the treatment became apparent. The study shows that secondary order lasix overnight delivery brain injury can be reduced by washing away the harmful debris of IVH. No other treatment for post-haemorrhagic ventricular dilatation has been shown to be beneficial in a randomised controlled trial.

Less invasive approaches to CSF drainage at different thresholds of ventricular enlargement later in the clinical course have not been associated with similar advantage. However the DRIFT treatment is complex and invasive order lasix overnight delivery and could only be provided in a small number of specialist referral centres and logistical challenges will need to be overcome to evaluate the treatment approach further. See page F466Chest compressionsWith a stable infant in the neonatal unit, it is common to review the events of the initial stabilisation and to speculate on whether chest compressions were truly needed to establish an effective circulation, or whether their use reflected clinician uncertainty in the face of other challenges.

Anne Marthe Boldinge and colleagues provide some objective data on the subject. They analysed videos that were recorded during neonatal stabilisation in a single order lasix overnight delivery centre with 5000 births per annum. From a birth population of almost 1200 infants there were good quality video recordings from 327 episodes of initial stabilisation where positive pressure ventilation was provided and 29 of these episodes included the provision of chest compressions, mostly in term infants.

6/29 of the infants who received chest compressions were retrospectively judged to have needed them. 8/29 had order lasix overnight delivery adequate spontaneous respiration. 18/29 received ineffective positive pressure ventilation prior to chest compressions.

5/29 had a heart rate greater than 60 beats per minute at order lasix overnight delivery the time of chest compressions. A consistent pattern of ventilation corrective actions was not identified. One infant received chest compressions without prior heart rate assessment.

See page 545Propofol for neonatal endotracheal intubationMost clinicians provide sedation/analgesia for neonatal intubations but there is still a lot of order lasix overnight delivery uncertainty about the best approach. Ellen de Kort and colleagues set out to identify the dose of propofol that would provide adequate sedation for neonatal intubation without side-effects. They conducted a dose-finding trial which evaluated a range of doses in infants of different gestations.

They ended their study after 91 infants because they order lasix overnight delivery only achieved adequate sedation without side effects in 13% of patients. Hypotension (mean blood pressure below post-mentrual age in the hour after treatment) was observed in 59% of patients. See page 489Growth to early adulthood following extremely preterm birthThe EPICure cohort comprised all babies born at 25 completed weeks of gestation or less in all 276 maternity units in the UK and Ireland from March to December 1995.

Growth data into adulthood are sparse for such immature infants order lasix overnight delivery. Yanyan Ni and colleagues report the growth to 19 years of 129 of the cohort in comparison with contemporary term born controls. The extremely preterm infants were on average 4.0 cm shorter and 6.8 kg lighter with order lasix overnight delivery a 1.5 cm smaller head circumference relative to controls at 19 years.

Body mass index was significantly elevated to +0.32 SD. With practice changing to include the provision of life sustaining treatment to greater numbers of infants born at 22 and 23 weeks of gestation there is a strong case for further cohort studies to include this population of infants. See page F496Premature birth is a worldwide problem, and the most significant cause of loss order lasix overnight delivery of disability-adjusted life years in children.

Impairment and disability among survivors are common. Cerebral palsy is diagnosed in around 10% of infants born before 33 weeks of gestation, although the rates approximately double in the smallest and most vulnerable infants, and other motor disturbances are being detected in 25%–40%. Cognitive, socialisation and behavioural problems are apparent in around half of preterm infants, and there is increased incidence of neuropsychiatric disorders, which order lasix overnight delivery develop as the children grow older.

Adults born preterm are approximately seven times more likely to be diagnosed with bipolar disease.1 2The neuropathological basis for these long-term and debilitating disorders is often unclear. Brain imaging by ultrasound or MRI shows that only a relatively small proportion of infants have significant destructive brain lesions, and these major lesions are not detected commonly enough to account for the prevalence of long-term impairments. However, abnormalities of brain growth and maturation are common, and it is now apparent that, in addition to recognisable cerebral damage, adverse neurological, cognitive and psychiatric outcomes are consistently associated with abnormal cerebral maturation and development.Currently, most clinical decision-making remains focused around a number of well-described cerebral lesions order lasix overnight delivery usually detected in routine practice using cranial ultrasound.

Periventricular haemorrhage is common. Severe haemorrhages are associated with long-term adverse outcomes, and in infants born before 33 weeks of gestation, haemorrhagic parenchymal infarction predicts motor deficits ….

Lasix patient teaching

A new lasix patient teaching strategy for modeling the spread of hypertension medications incorporates smartphone-captured hop over to here data on people's movements and shows promise for aiding development of optimal lockdown policies. Ritabrata Dutta of Warwick University, U.K., and colleagues present these findings in the open-access journal PLOS Computational Biology.Evidence shows that lockdowns are effective in mitigating the spread of hypertension medications. However, they do come at a high economic cost, and in practice, not everybody follows government lasix patient teaching guidance on lockdowns. Thus, Dutta and colleagues propose, an optimal lockdown strategy would balance between controlling the ongoing hypertension medications lasix and minimizing the economic costs of lockdowns.To help guide such a strategy, the researchers developed new mathematical models that simulate the spread of hypertension medications.

The models focus on England and France and -- using a statistical approach known as approximate Bayesian computation -- they incorporate both lasix patient teaching public health data and data on changes in people's movements, as captured by Google via Android devices. This mobility data serves as a measure of the effectiveness of lockdown policies.Then, the researchers demonstrated how their models could be applied to design optimal lockdown strategies for England and France using a mathematical technique called optimal control. They showed cheap lasix canada that it is possible to design effective lockdown protocols that allow partial lasix patient teaching reopening of workplaces and schools, while taking into account both public health costs and economic costs. The models can be updated in real time, and they can be adapted to any country for which reliable public health and Google mobility data are available."Our work opens the door to a larger integration between epidemiological models and real-world data to, through the use of supercomputers, determine best public policies to mitigate the effects of a lasix," Dutta says.

"In a not-so-distant future, policy makers may be able to express certain prioritization criteria, and a computational engine, with an extensive use of different datasets, could determine the best course of action."Next, the lasix patient teaching researchers plan to refine their country-wide models to work at smaller scales. Specifically, each of the 348 local district authorities of the U.K.The researchers add, "The integration of big data, epidemiological models and supercomputers can help us design an optimal lockdown strategy in real time, while balancing both public health and economic costs." Story Source. Materials provided by PLOS lasix patient teaching. Note.

Content may be edited for style and length..

A new strategy for modeling the spread of hypertension medications incorporates smartphone-captured order lasix overnight delivery data on people's movements and shows promise for aiding development of optimal lockdown policies. Ritabrata Dutta of Warwick University, U.K., and colleagues present these findings in the open-access journal PLOS Computational Biology.Evidence shows that lockdowns are effective in mitigating the spread of hypertension medications. However, they do come at a high economic cost, and in practice, not everybody follows government guidance order lasix overnight delivery on lockdowns.

Thus, Dutta and colleagues propose, an optimal lockdown strategy would balance between controlling the ongoing hypertension medications lasix and minimizing the economic costs of lockdowns.To help guide such a strategy, the researchers developed new mathematical models that simulate the spread of hypertension medications. The models focus on England and France and -- using a statistical approach known as approximate Bayesian computation -- they incorporate both public health data order lasix overnight delivery and data on changes in people's movements, as captured by Google via Android devices. This mobility data serves as a measure of the effectiveness of lockdown policies.Then, the researchers demonstrated how their models could be applied to design optimal lockdown strategies for England and France using a mathematical technique called optimal control.

They showed that it is possible to order lasix overnight delivery design effective lockdown protocols that allow partial reopening of workplaces and schools, while taking into account both public health costs and economic costs. The models can be updated in real time, and they can be adapted to any country for which reliable public health and Google mobility data are available."Our work opens the door to a larger integration between epidemiological models and real-world data to, through the use of supercomputers, determine best public policies to mitigate the effects of a lasix," Dutta says. "In a not-so-distant future, policy makers may be order lasix overnight delivery able to express certain prioritization criteria, and a computational engine, with an extensive use of different datasets, could determine the best course of action."Next, the researchers plan to refine their country-wide models to work at smaller scales.

Specifically, each of the 348 local district authorities of the U.K.The researchers add, "The integration of big data, epidemiological models and supercomputers can help us design an optimal lockdown strategy in real time, while balancing both public health and economic costs." Story Source. Materials provided by order lasix overnight delivery PLOS. Note.

Content may be edited for style and length..

Buy lasix 40mg online

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Stress and mental health of tribal and non tribal female school teachers in Jharkhand, India. Int J Sci Res Publicat 2012;2:2250-3153. 29.Longkumer I, Borooah PI. Knowledge about attitudes toward mental disorders among Nagas in North East India. IOSR J Humanities Soc Sci 2013;15:41-7.

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

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Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India. A cluster-randomised controlled trial. Lancet 2010;375:1182-92. 36.Aparajita C, Anita KM, Arundhati R, Chetana P. Assessing Social-support network among the socio culturally disadvantaged children in India.

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

41.Nandi DN, Banerjee G, Chowdhury AN, Banerjee T, Boral GC, Sen B. Urbanization and mental morbidity in certain tribal communities in West Bengal. Indian J Psychiatry 1992;34:334-9. [PUBMED] [Full text] 42.Hackett RJ, Sagdeo D, Creed FH. The physical and social associations of common mental disorder in a tribal population in South India.

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

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

How to order lasix overnight delivery cite this article:Singh OP. Psychiatry research in India. Closing the research gap order lasix overnight delivery.

Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science. Research in India in general and medical order lasix overnight delivery research in particular is always being criticized for lack of innovation and originality required for the delivery of health services suitable to Indian conditions. Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism.

It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers order lasix overnight delivery published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up to the mark and is not commensurate with the magnitude of the disease burden in India. According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases.

The research conducted elsewhere may not be generalized to the Indian population owing to differences in biology, health-care systems, health practices, culture, and socioeconomic standards order lasix overnight delivery. Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017–2018) of the Department of Health Research observed that “the biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.”[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research.

While ICMR has a budget of 232 million dollars per year on order lasix overnight delivery health research, it is zilch in comparison to the annual budget expenditure of the National Institute of Health, USA, on biomedical research which is 32 billion dollars.The lacuna of quality research is not merely due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established order lasix overnight delivery research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical institutions.

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

PGIMER, Chandigarh. CMC, Vellore order lasix overnight delivery. And SGIMS, Lucknow are among the top ten medical institutions in terms of publication in peer-reviewed journals, around 332 (57.3%) medical colleges have no research paper published in a decade between 2004 and 2014.[2]The research in psychiatry is realistically dominated by major research institutes which are doing commendable work, but there is a substantial lack of contemporary research originating from other centers.

Dr. Chittaranjan Andrade (NIMHANS, Bengaluru) and Dr. K Jacob (CMC, Vellore) recently figured in the list of top 2% psychiatry researchers in the world from India in psychiatry.[3] Most of the research conducted in the field of psychiatry are limited to caregivers' burden, pathways of care, and other topics which can be done in limited resources available to psychiatry departments.

While all these areas of work are important in providing proper care and treatment, there is overabundance of research in these areas.The Government of India is aggressively looking forward to enhancing the quality of research and is embarking on an ambitious project of purchasing all major journals and providing free access to universities across the country. The India Genome Project started in January, 2020, is a good example of collaboration. While all these actions are laudable, a lot more needs to be done.

Following are some measures which will reduce the gap:Research proposals at the level of protocol can be guided and mentored by institutes. Academic committees of different zones and journals can help in this endeavorBreaking the cubicles by establishing a collaboration between medical colleges and various institutes. While there is a lack of resources available in individual departments, there are universities and institutes with excellent infrastructure.

They are not aware of the requirements of the field of psychiatry and research questions. Creation of an alliance will enhance the quality of research work. Some of such institutes include Centre for Neuroscience, Indian Institute of Science, Bengaluru.

CSIR-Institute of Genomics and Integrative Biology, New Delhi. And National Institute of Biomedical Genomics, KalyaniInitiation and establishment of interactive and stable relationships between basic scientists and clinical and technological experts will enhance the quality of research work and will lead to translation of basic biomedical research into real-time applications. For example, work on artificial intelligence for mental health.

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

References 1.2.Nagoba B, Davane M. Current status of medical research in India. Where are we?.

Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J. Updated science-wide author databases of standardized citation indicators.

PLoS Biol 2020;18:e3000918. Correspondence Address:Dr. Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_1362_2Abstract Background.

The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly.Aim. The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research.Materials and Methods. Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis.

PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies. Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme. Studies were summarized and reported descriptively.Results.

Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas. Alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services.

Sociocultural factors play a major role in understanding and determining mental disorders.Conclusion. This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality.

Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.Keywords. India, mental health, scheduled tribesHow to cite this article:Devarapalli S V, Kallakuri S, Salam A, Maulik PK. Mental health research on scheduled tribes in India.

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

In northeastern states, they constitute 65% or more of the total population.[5] The ST communities are identified as culturally or ethnographically unique by the Indian Constitution. They are populations with poorer health indicators and fewer health-care facilities compared to non-ST rural populations, even when within the same state, and often live in demarcated geographical areas known as ST areas.[4]As per the National Family Health Survey, 2015–2016, the health indicators such as infant mortality rate (IMR) is 44.4, under five mortality rate (U5MR) is 57.2, and anemia in women is 59.8 for STs – one of the most disadvantaged socioeconomic groups in India, which are worse compared to other populations where IMR is 40.7, U5MR is 49.7, and anemia in women among others is 53.0 in the same areas.[6] Little research is available on the health of ST population. Tribal mental health is an ignored and neglected area in the field of health-care services.

Further, little data are available about the burden of mental disorders among the tribal communities. Health research on tribal populations is poor, globally.[7] Irrespective of the data available, it is clear that they have worse health indicators and less access to health facilities.[8] Even less is known about the burden of mental disorders in ST population. It is also found that the traditional livelihood system of the STs came into conflict with the forces of modernization, resulting not only in the loss of customary rights over the livelihood resources but also in subordination and further, developing low self-esteem, causing great psychological stress.[4] This community has poor health infrastructure and even less mental health resources, and the situation is worse when compared to other communities living in similar areas.[9],[10]Only 15%–25% of those affected with mental disorders in LMICs receive any treatment for their mental illness,[11] resulting in a large “treatment gap.”[12] Treatment gaps are more in rural populations,[13] especially in ST communities in India, which have particularly poor infrastructure and resources for health-care delivery in general, and almost no capacity for providing mental health care.[14]The aim of this systematic review was to explore the extent and nature of mental health research on ST population in India and to identify gaps and inform future research.

Materials and Methods Search strategyWe searched major databases (PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar) and made hand searches from January 1980 to December 2018 to identify relevant literature. Hand search refers to searching through medical journals which are not indexed in the major electronic databases such as Embase, for instance, searching for Indian journals in IndMed database as most of these journals are not available in major databases. Physical search refers to searching the journals that were not available online or were not available online during the study years.

We used relevant Medical Subject Heading and key terms in our search strategy, as follows. €œMental health,” “Mental disorders,” “Mental illness,” “Psychiatry,” “Scheduled Tribe” OR “Tribe” OR “Tribal Population” OR “Indigenous population,” “India,” “Psych*” (Psychiatric, psychological, psychosis).Inclusion criteriaStudies published between January 1980 and December 2018 were included. Studies on mental disorders were included only when they focused on ST population.

Both qualitative and quantitative studies on mental disorders of ST population only were included in the analysis.Exclusion criteriaStudies without any primary data and which are merely overviews and commentaries and those not focused on ST population were excluded from the analysis.Data management and analysisTwo researchers (SD and SK) initially screened the title and abstract of each record to identify relevant papers and subsequently screened full text of those relevant papers. Any disagreements between the researchers were resolved by discussion or by consulting with an adjudicator (PKM). From each study, data were extracted on objectives, study design, study population, study duration, interventions (if applicable), outcomes, and results.

Quality of the included studies was assessed, independently by three researchers (SD, SK, and AS), using Critical Appraisal Checklist developed by Critical Appraisal Skills Programme (CASP).[15] After a thorough qualitative assessment, all quantitative data were generated and tabulated. A narrative description of the studies is provided in [Table 1] using some broad categories. Results Search resultsOur search retrieved 2306 records (which included hand-searched articles), of which after removing duplicates, title and abstracts of 2278 records were screened.

Of these, 178 studies were deemed as potentially relevant and were reviewed in detail. Finally, we excluded 146 irrelevant studies and 32 studies were included in the review [Figure 1].Quality of the included studiesSummary of quality assessment of the included studies is reported in [Table 2]. Overall, nine studies were of poor quality, twenty were of moderate quality, and three studies were of high quality.

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

Nonresponse not addressed. Risk factors not measured correctly. And methods used were not sufficiently described to repeat them.

Studies under the moderate quality did not have a representative sample. Non-responders categories was not addressed. Risk factors were not measured correctly.

And methods used were not sufficiently described to allow the study to be replicated by other researchers.The included studies covered three broad categories. Alcohol and substance use disorders, CMD (depression, anxiety, stress, and suicide risk), socio-cultural aspects, and access to mental health services.Alcohol and substance use disordersFive studies reviewed the consumption of alcohol and opioid. In an ethnographic study conducted in three western districts in Rajasthan, 200 opium users were interviewed.

Opium consumption was common among both younger and older males during nonharvest seasons. The common causes for using opium were relief of anxiety related to crop failure due to drought, stress, to get a high, be part of peers, and for increased sexual performance.[16]In a study conducted in Arunachal Pradesh involving a population of more than 5000 individuals, alcohol use was present in 30% and opium use in about 5% adults.[17] Contrary to that study, in Rajasthan, the prevalence of opium use was more in women and socioeconomic factors such as occupation, education, and marital status were associated with opium use.[16] The prevalence of opium use increased with age in both sexes, decreased with increasing education level, and increased with employment. It was observed that wages were used to buy opium.

In the entire region of Chamlang district of Arunachal Pradesh, female substance users were almost half of the males among ST population.[17] Types of substance used were tobacco, alcohol, and opium. Among tobacco users, oral tobacco use was higher than smoking. The prevalence of tobacco use was higher among males, but the prevalence of alcohol use was higher in females, probably due to increased access to homemade rice brew generally prepared by women.

This study is unique in terms of finding a strong association with religion and culture with substance use.[18]Alcohol consumption among Paniyas of Wayanad district in Kerala is perceived as a male activity, with many younger people consuming it than earlier. A study concluded that alcohol consumption among them was less of a “choice” than a result of their conditions operating through different mechanisms. In the past, drinking was traditionally common among elderly males, however the consumption pattern has changed as a significant number of younger men are now drinking.

Drinking was clustered within families as fathers and sons drank together. Alcohol is easily accessible as government itself provides opportunities. Some employers would provide alcohol as an incentive to attract Paniya men to work for them.[19]In a study from Jharkhand, several ST community members cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol.

Societal acceptance of drinking alcohol and peer pressure, as well as high emotional problems, appeared to be the major etiology leading to higher prevalence of substance dependence in tribal communities.[20] Another study found high life time alcohol use prevalence, and the reasons mentioned were increased poverty, illiteracy, increased stress, and peer pressure.[21] A household survey from Chamlang district of Arunachal Pradesh revealed that there was a strong association between opium use and age, occupation, marital status, religion, and ethnicity among both the sexes of STs, particularly among Singhpho and Khamti.[15] The average age of onset of tobacco use was found to be 16.4 years for smoked and 17.5 years for smokeless forms in one study.[22]Common mental disorders and socio-cultural aspectsSuicide was more common among Idu Mishmi in Roing and Anini districts of Arunachal Pradesh state (14.2%) compared to the urban population in general (0.4%–4.2%). Suicides were associated with depression, anxiety, alcoholism, and eating disorders. Of all the factors, depression was significantly high in people who attempted suicide.[24] About 5% out of 5007 people from thirty villages comprising ST suffered from CMDs in a study from West Godavari district in rural Andhra Pradesh.

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

The study found that among the three factors namely stress, marital status, and ethnicity, ethnicity was found to affect mental health of the school teachers most. It found a positive relationship between mental health and socioeconomic status, with an inverse relationship showing that as income increased, the prevalence of depression decreased.[28] A study among Ao-Nagas in Nagaland found that 74.6% of the population attributed mental health problems to psycho-social factors and a considerable proportion chose a psychiatrist or psychologist to overcome the problem. However, 15.4% attributed mental disorders to evil spirits.

About 47% preferred to seek treatment with a psychiatrist and 25% preferred prayers. Nearly 10.6% wanted to seek the help of both the psychiatrist and prayer group and 4.4% preferred traditional healers.[28],[29] The prevalence of Down syndrome among the ST in Chikhalia in Barwani district of Madhya Pradesh was higher than that reported in overall India. Three-fourth of the children were the first-born child.

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

The key objectives were to use task sharing, training of primary health workers, implementing evidence-based clinical decision support tools on a mobile platform, and providing mental health services to rural population. The study included 238 adults suffering from CMD. During the intervention period, 12.6% visited the primary health-care doctors compared to only 0.8% who had sought any care for their mental disorders prior to the intervention.

The study also found a significant reduction in the depression and anxiety scores at the end of intervention and improvements in stigma perceptions related to mental health.[14] A study in Gudalur and Pandalur Taluks of Nilgiri district from Tamil Nadu used low cost task shifting by providing community education and identifying and referring individuals with psychiatric problems as effective strategies for treating mental disorders in ST communities. Through the program, the health workers established a network within the village, which in turn helped the patients to interact with them freely. Consenting patients volunteered at the educational sessions to discuss their experience about the effectiveness of their treatment.

Community awareness programs altered knowledge and attitudes toward mental illness in the community.[33] A study in Nilgiri district, Tamil Nadu, found that the community had been taking responsibility of the patients with the system by providing treatment closer to home without people having to travel long distances to access care. Expenses were reduced by subsidizing the costs of medicine and ensuring free hospital admissions and referrals to the people.[34] A study on the impact of gender, socioeconomic status, and age on mental health of female factory workers in Jharkhand found that the ST women were more likely to face stress and hardship in life due to diverse economic and household responsibilities, which, in turn, severely affected their mental health.[35] Prevalence of mental health morbidity in a study from the Sunderbans delta found a positive relation with psycho-social stressors and poor quality of life. The health system in that remote area was largely managed by “quack doctors” and faith healers.

Poverty, illiteracy, and detachment from the larger community helped reinforce superstitious beliefs and made them seek both mental and physical health care from faith healers.[36] In a study among students, it was found that children had difficulties in adjusting to both ethnic and mainstream culture.[27] Low family income, inadequate housing, poor sanitation, and unhealthy and unhygienic living conditions were some environmental factors contributing to poor physical and mental growth of children. It was observed that children who did not have such risk factors maintained more intimate relations with the family members. Children belonging to the disadvantaged environment expressed their verbal, emotional need, blame, and harm avoidances more freely than their counterparts belonging to less disadvantaged backgrounds.

Although disadvantaged children had poor interfamilial interaction, they had better relations with the members outside family, such as peers, friends, and neighbors.[37] Another study in Jharkhand found that epilepsy was higher among ST patients compared to non-ST patients.[31] Most patients among the ST are irregular and dropout rates are higher among them than the non-ST patients. Urbanization per se exerted no adverse influence on the mental health of a tribal community, provided it allowed preservation of ethnic and cultural practices. Women in the ST communities were less vulnerable to mental illness than men.

This might be a reflection of their increased responsibilities and enhanced gender roles that are characteristic of women in many ST communities.[38] Data obtained using culturally relevant scales revealed that relocated Sahariya suffer a lot of mental health problems, which are partially explained by livelihood and poverty-related factors. The loss of homes and displacement compromise mental health, especially the positive emotional well-being related to happiness, life satisfaction, optimism for future, and spiritual contentment. These are often not overcome even with good relocation programs focused on material compensation and livelihood re-establishment.[39] Discussion This systematic review is to our knowledge the first on mental health of ST population in India.

Few studies on the mental health of ST were available. All attempts including hand searching were made to recover both published peer-reviewed papers and reports available on the website. Though we searched gray literature, it may be possible that it does not capture all articles.

Given the heterogeneity of the papers, it was not possible to do a meta-analysis, so a narrative review was done.The quality of the studies was assessed by CASP. The assessment shows that the research conducted on mental health of STs needs to be carried out more effectively. The above mentioned gaps need to be filled in future research by considering the resources effectively while conducting the studies.

Mental and substance use disorders contribute majorly to the health disparities. To address this, one needs to deliver evidence-based treatments, but it is important to understand how far these interventions for the indigenous populations can incorporate cultural practices, which are essential for the development of mental health services.[30] Evidence has shown a disproportionate burden of suicide among indigenous populations in national and regional studies, and a global and systematic investigation of this topic has not been undertaken to date. Previous reviews of suicide epidemiology among indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth, high-income countries, or regions such as Oceania or the Arctic.[46] The only studies in our review which provided data on suicide were in Idu Mishmi, an isolated tribal population of North-East India, and tribal communities from Sunderban delta.[24],[37] Some reasons for suicide in these populations could be the poor identification of existing mental disorders, increased alcohol use, extreme poverty leading to increased debt and hopelessness, and lack of stable employment opportunities.[24],[37] The traditional consumption pattern of alcohol has changed due to the reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement.[19],[20]Faith healers play a dominant role in treating mental disorders.

There is less awareness about mental health and available mental health services and even if such knowledge is available, access is limited due to remoteness of many of these villages, and often it involves high out-of-pocket expenditure.[35] Practitioners of modern medicine can play a vital role in not only increasing awareness about mental health in the community, but also engaging with faith healers and traditional medicine practitioners to help increase their capacity to identify and manage CMDs that do not need medications and can be managed through simple “talk therapy.” Knowledge on symptoms of severe mental disorders can also help such faith healers and traditional medicine practitioners to refer cases to primary care doctors or mental health professionals.Remote settlements make it difficult for ST communities to seek mental health care. Access needs to be increased by using solutions that use training of primary health workers and nonphysician health workers, task sharing, and technology-enabled clinical decision support tools.[3] The SMART Mental Health project was delivered in the tribal areas of Andhra Pradesh using those principles and was found to be beneficial by all stakeholders.[14]Given the lack of knowledge about mental health problems among these communities, the government and nongovernmental organizations should collect and disseminate data on mental disorders among the ST communities. More research funding needs to be provided and key stakeholders should be involved in creating awareness both in the community and among policy makers to develop more projects for ST communities around mental health.

Two recent meetings on tribal mental health – Round Table Meeting on Mental Health of ST Populations organized by the George Institute for Global Health, India, in 2017,[51] and the First National Conference on Tribal Mental Health organized by the Indian Psychiatric Society in Bhubaneswar in 2018 – have identified some key areas of research priority for mental health in ST communities. A national-level policy on mental health of tribal communities or population is advocated which should be developed in consultation with key stakeholders. The Indian Psychiatric Society can play a role in coordinating research activities with support of the government which can ensure regular monitoring and dissemination of the research impact to the tribal communities.

There is a need to understand how mental health symptoms are perceived in different ST communities and investigate the healing practices associated with distress/disaster/death/loss/disease. This could be done in the form of cross-sectional or cohort studies to generate proper evidence which could also include the information on prevalence, mental health morbidity, and any specific patterns associated with a specific disorder. Future research should estimate the prevalence of mental disorders in different age groups and gender, risk factors, and the influence of modernization.

Studies should develop a theoretical model to understand mental disorders and promote positive mental health within ST communities. Studies should also look at different ST communities as cultural differences exist across them, and there are also differences in socioeconomic status which impact on ability to access care.Research has shown that the impact and the benefits are amplified when research is driven by priorities that are identified by indigenous communities and involve their active participation. Their knowledge and perspectives are incorporated in processes and findings.

Reporting of findings is meaningful to the communities. And indigenous groups and other key stakeholders are engaged from the outset.[47] Future research in India on ST communities should also adhere to these broad principles to ensure relevant and beneficial research, which have direct impact on the mental health of the ST communities.There is also a need to update literature related to mental health of ST population continuously. Develop culturally appropriate validated instruments to measure mental morbidity relevant to ST population.

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

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J Cross Cultl Psychol 2015;46:435-53. 40.Giri DK, Chaudhary S, Govinda M, Banerjee A, Mahto AK, Chakravorty PK. Utilization of psychiatric services by tribal population of Jharkhand through community outreach programme of RINPAS.

Eastern J Psychiatry 2007;10:25-9. 41.Nandi DN, Banerjee G, Chowdhury AN, Banerjee T, Boral GC, Sen B. Urbanization and mental morbidity in certain tribal communities in West Bengal.

Indian J Psychiatry 1992;34:334-9. [PUBMED] [Full text] 42.Hackett RJ, Sagdeo D, Creed FH. The physical and social associations of common mental disorder in a tribal population in South India.

Soc Psychiatry Psychiatr Epidemiol 2007;42:712-5. 43.Raina SK, Raina S, Chander V, Grover A, Singh S, Bhardwaj A. Development of a cognitive screening instrument for tribal elderly population of Himalayan region in northern India.

J Neurosci Rural Pract 2013;4:147-53. [PUBMED] [Full text] 44.Raina SK, Raina S, Chander V, Grover A, Singh S, Bhardwaj A. Identifying risk for dementia across populations.

A study on the prevalence of dementia in tribal elderly population of Himalayan region in Northern India. Ann Indian Acad Neurol 2013;16:640-4. [PUBMED] [Full text] 45.Raina SK, Chander V, Raina S, Kumar D.

Feasibility of using everyday abilities scale of India as alternative to mental state examination as a screen in two-phase survey estimating the prevalence of dementia in largely illiterate Indian population. Indian J Psychiatry 2016;58:459-61. [PUBMED] [Full text] 46.Diwan R.

Mental health of tribal male-female factory workers in Jharkhand. IJAIR 2012;2278:234-42. 47.Banerjee T, Mukherjee SP, Nandi DN, Banerjee G, Mukherjee A, Sen B, et al.

Psychiatric morbidity in an urbanized tribal (Santal) community - A field survey. Indian J Psychiatry 1986;28:243-8. [PUBMED] [Full text] 48.Leske S, Harris MG, Charlson FJ, Ferrari AJ, Baxter AJ, Logan JM, et al.

Systematic review of interventions for Indigenous adults with mental and substance use disorders in Australia, Canada, New Zealand and the United States. Aust N Z J Psychiatry 2016;50:1040-54. 49.Pollock NJ, Naicker K, Loro A, Mulay S, Colman I.

Global incidence of suicide among Indigenous peoples. A systematic review. BMC Med 2018;16:145.

50.Silburn K, et al. Evaluation of the Cooperative Research Centre for Aboriginal Health (Australian institute for primary care, trans.). Melbourne.

Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].

Lasix online

What was the real nature of lasix online cystic fibrosis, a devastating illness that was killing http://www.findlayillinois.net/how-to-get-cialis-without-a-doctor/ young children and had been routinely misdiagnosed, for years and years?. FRANCIS COLLINS. So, I’m Francis Collins. I’m a lasix online physician and a scientist and currently the director of the National Institutes of Health. KATIE HAFNER.

In addition to leading the NIH, Dr. Collins in the 1990s led the Human Genome Project, the massive effort that lasix online unraveled the mysteries of DNA. Dr. Collins knows a little about Dorothy Andersen. FRANCIS COLLINS lasix online.

I know her as the person who, in 1938, described this disorder, cystic fibrosis of the pancreas. KATIE HAFNER. But he was a lasix online bit chagrined to admit, that’s pretty much all he knows. FRANCIS COLLINS. I don’t know much about her career, her person, as somebody who must have traveled an interesting journey as a woman working in medical research.

KATIE HAFNER lasix online. As one of the scientists who isolated the cystic fibrosis gene in 1989, Dr. Collins stood on the shoulders of path-breaking scientists like Dr. Dorothy Andersen lasix online. He is also an outspoken champion of women in science.

So if he doesn’t know much about her, who does?. In this episode, we’re going to lasix online tackle two mysteries. The first is the disease itself–cystic fibrosis. In the 1930s, it was a cruel killer of infants that was routinely misdiagnosed—until Dorothy Andersen solved the puzzle. And then we’ll turn to the mystery of Dorothy Andersen herself, an ingenious medical sleuth who left behind very few clues for those lasix online of us trying to understand what made her tick.

Dorothy Andersen stood out. She was one of the very few women working as a physician in the first half of the twentieth century. BIJAL TRIVEDI lasix online. In the thirties, women made up only five percent of practicing physicians, so she was a rarity. KATIE HAFNER.

That’s Bijal Trivedi, a science journalist whose book, “Breath from Salt,” describes the history of cystic fibrosis lasix online. BIJAL TRIVEDI. Dorothy Andersen had always wanted to practice medicine. She was a determined woman and she wanted to have a career, and settled for becoming lasix online a pathologist. KATIE HAFNER.

At the time, there were few options for women with medical degrees–many hospitals wouldn’t hire women, and even if they did, women usually got pigeonholed to specialties like gynecology or psychiatry. In those days, men and women alike often objected to being seen by female physicians, which also led many women to pathology, where doctors rarely interacted lasix online with patients. Pathologists study the nature and cause of disease. And in the 1930’s, one of the only ways to investigate how disease ravaged the body was through autopsies. That’s how it came to pass one lasix online day in 1935 that Dr.

Dorothy Andersen stood at a stainless steel table in the basement of Columbia’s Babies Hospital in Washington Heights. Her task was indescribably tragic, but she was all business as she set upon it—to dissect the organs of yet another child who had died. This child was lasix online a 3 year old girl. The girl had come into the hospital a year before... BIJAL TRIVEDI.

...and she lasix online looked terrible. She had a distended belly, skinny limbs, foul, persistent diarrhea, and she had been diagnosed with celiac disease and sent home. But there she was a year later, and she was dead. And so Dorothy Andersen started doing this autopsy and slowly began lasix online to realize that this was not celiac disease. KATIE HAFNER.

At the time, it was common for children with cystic fibrosis to be misdiagnosed with celiac disease– A lot of people are sensitive to gluten, and a subset of those people have full-blown celiac disease—an immune reaction to wheat and rye that inflames the intestine and can cause severe GI symptoms. This inflammation is also a symptom of cystic lasix online fibrosis. Of course these are two very different diseases with very different treatments and outcomes. But, at the time, the misdiagnosis was understandable. And there were two lasix online reasons for it.

First, they had the GI symptoms in common. That was number one. And number two lasix online. Frequent pneumonias and breathing problems were misattributed to the malnutrition that accompanies celiac disease instead of a problem with the lungs. So as Dorothy Andersen began examining the organs of the 3-year-old child...

BIJAL TRIVEDI lasix online. ...she realized that there were a lot of differences, and the most profound differences were in the lungs. And as she started to look into the airways of the lungs, she saw that they were, they were plugged full of mucus, thick, sticky, green mucus. But when she cut into the pancreas, I mean, she could barely get lasix online the scalpel in. And when she sort of tried to cut, she heard a scraping sound as if she were cutting through grit or sand.

All she could see was this fibrous, tough material, completely enveloping the whole gland. So, you know, she knew this was lasix online something very, very different. WILLIAM SKACH. You know, with Dorothy Anderson's description of the actual entity of CF, it became clear that it was multi-system. KATIE lasix online HAFNER That’s Dr.

William Skach, the outgoing Chief Scientific Officer of the Cystic Fibrosis Foundation. WILLIAM SKACH. It did not just affect the lungs or lasix online the pancreas, but affected multiple tissues. KATIE HAFNER. To understand just how cystic fibrosis affects multiple systems, we need to take a brief medical excursion into the body–and specifically, its tubes.

Bear with lasix online me. One of the miracles of our construction is that we’re filled with tubes–conduits that move stuff from one place to another. Perhaps the most familiar ones are blood vessels–an intricate arborized network of miles of tubes that circulate blood. Block these tubes–most commonly by a clot–and the tissue at lasix online the far end dies. When it’s the brain, it’s a stroke.

When it’s the heart itself, it’s a heart attack. The lungs also have blood vessels, but the most important tubes in and out of the lungs are the ones that allow for oxygen to come in and lasix online carbon dioxide to come out. If those tubes are blocked, we can’t live. The pancreas also has tubes–the main one being the pancreatic duct. The miracle here is that the pancreas, which is producing digestive enzymes lasix online capable of breaking down a piece of steak in our intestine, doesn’t digest itself.

The reason is that the corrosive enzymes flow into these tubes, and from there they enter the intestines. But block these tubes and the juices back up into the pancreas itself, to devastating effect. What Dorothy Andersen discovered was that the primary problem with these patients was very lasix online different from what causes celiac disease. And so Dorothy Andersen’s discovery was that the lungs and pancreas shared the same fatal problem—that the real issue wasn’t inflammation in the wall of the intestine. It was the clogging of the tubes in the pancreas and the lungs.

Something was gumming up the tubes like molasses lasix online in a straw. Again, Bijal Trivedi. BIJAL TRIVEDI. With this disease, patients get persistent lung s that destroy lung tissue and limit the lasix online ability to breathe. This thick mucus also builds up in their airways, so they can’t actually inhale properly.

They can’t take a full breath and breathe deeply. They can’t laugh lasix online properly, because they don’t have the air to laugh. SARA KOMINSKY. It feels like you’re suffocating to death. And at the point before my first lung transplant, I couldn’t even walk across the room, even on oxygen, without lasix online gasping and feeling like I’d… throw up because it took so much effort.

KATIE HAFNER. That was Sara Kominsky who’s 50 now, describing what it’s like to have cystic fibrosis. Next is Malory Woodruff, lasix online who’s in her mid-30s. MALLORY WOODRUFF. I started getting winded a lot easier.

I started producing more mucus, cough, coughing up plugs lasix online. The plugs started getting, you know, thicker and greener, yuckier. And then, by the time I was in college...it was really hard to get to class, honestly. SARA KOMINSKY lasix online. All the other CF patients I met during my childhood and young adulthood, by the time I was in my mid-20s early-30s, all of them had passed away.

KATIE HAFNER. In the 1970s and 80s, when Sara and Mallory were born, CF patients rarely lasix online lived past their teens. But their prospects are improving. Today, the life expectancy for CF patients is around 50. And a breakthrough drug called Trikafta was approved by the FDA just lasix online two years ago.

It’s very expensive, but Trikafta promises to dramatically improve this prognosis and the patients’ quality of life. Dorothy Andersen wasn’t setting out to identify an entirely different disease. But she kept an open mind, open enough to process surprising findings and consider the possibility that the medical community’s prior understanding lasix online was just plain wrong. BRIAN O’SULLIVAN. Well, I have Dorothy Andersen’s papers right here on my desk.

In fact, I keep them in a bag that I bring back and forth to work pretty much all the lasix online time. KATIE HAFNER. That’s Brian O’Sullivan, a pediatric pulmonologist who teaches at the Geisel School of Medicine at Dartmouth. BRIAN O’SULLIVAN lasix online. And the first is one from the American Journal of Diseases of Childhood in 1938.

And it’s title is “Cystic Fibrosis of the Pancreas and Its Relation to Celiac Disease. A Clinical and Pathological Study,” lasix online by Dorothy H. Andersen, MD, New York. KATIE HAFNER:I first came across Dr. O’Sullivan’s name when he was quoted in a 2014 article in lasix online The Lancet, one of the most popular medical journals.

The article was a brief biographical sketch of Dr. Andersen. And it turns out that every year when Brian O’Sullivan lasix online lectures to first-year med students about cystic fibrosis... BRIAN O’SULLIVAN. The disease has obviously been around for millennia.

It’s a genetic disease lasix online. KATIE HAFNER. He makes a point of paying tribute to this key figure in the history of the disease. BRIAN O’SULLIVAN lasix online. I want to take a minute to call out Dorothy Andersen.

This is a woman who, you know, in the 1920’s, late twenties, early thirties when she was going to medical school, there weren’t a lot of women in medical school. And it’s funny, I’m looking out at the audience now, and it’s almost all women lasix online. But it was very different in the thirties. KATIE HAFNER. That 1938 paper he carries with him at all times was 50 pages lasix online long and written by a single author, which would be unheard of in today’s world of publishing, where there are usually at least half a dozen, and sometimes hundreds of authors on a paper.

BRIAN O’SULLIVAN. There’s the old saying, “Luck favors the prepared mind.” The luck was that she was in a position where she saw some children, unfortunately, who had died of this problem. The prepared mind is lasix online Dorothy. I mean, she’s just brilliant, and she put this puzzle together. And so she recognized that she was seeing a group of children who had some of the hallmarks of celiac disease but on autopsy had very different problems.

KATIE HAFNER lasix online. That 50 page paper she published reviewed 20 cases from Dr. Andersen’s own institution and many more from other places, in an era where there was no Google Scholar. BRIAN O’SULLIVAN lasix online. She must have spent hours in the library finding these articles and then writing to other physicians and seeing if she could get their slides from autopsies to be able to compare to what she was seeing.

KATIE HAFNER. She reviewed hundreds of pathology slides from other children lasix online believed to have died from celiac disease, until... BRIAN O’SULLIVAN. She really spelled out that she was identifying a completely different disease, and it was the first time it really was recognized as a separate entity. KATIE HAFNER lasix online.

And she didn’t stop there. After recognizing cystic fibrosis as something different, Dorothy Andersen went back to work, trying to understand as much as she could about the disease. And she lasix online started racking up a lot of firsts. SCOTT BAIRD. She was the first to diagnose CF in a living patient, the first to emphasize diet and pancreatic enzyme replacement therapy in CF, the first to successfully treat pulmonary in CF with antibiotics, and the first to recognize that CF was a hereditary disease expressed in the manner of a recessive trait.

KATIE HAFNER lasix online. Scott Baird is a pediatric critical care doctor at Columbia University Medical Center and he’s seen scores of CF patients throughout his clinical career. Like Dorothy Andersen before him, Dr. Baird has spent the bulk of his professional life at Columbia, lasix online so there’s a kinship there. And Scott Baird, it turns out, isn’t just a fan of Dr.

Andersen’s work. He’s on a quest to fill in the details of her life. SCOTT BAIRD lasix online. Dorothy Andersen, who never was specifically trained in pathology, never specifically trained in pediatrics, became a world-class pathologist, a world-class pediatrician, and clearly was a world-class researcher, somebody who was able to define and determine what might be associated with disease in patients, and who was able to push the boundaries. KATIE HAFNER.

Coming up, we’ll start to untangle more about this mysterious lasix online scientist. I’m Katie Hafner and this is Lost Women of Science. (AD) KATIE HAFNER. So now lasix online that we appreciate what Dorothy Andersen did, let’s try to unravel another mystery. Who she was.

Dorothy Hansine Anderson graduated from Johns Hopkins Medical School in 1926, one of only 5 women in her class. But Hopkins was well lasix online ahead of its time. When the medical school opened in 1893, there were three women admitted to the first class. Harvard Medical School wouldn’t officially admit its first women until 1945!. Here’s Brian lasix online O’Sullivan again.

BRIAN O’SULLIVAN:. Um, following that she went to Rochester and did an internship and then she wanted to become a surgeon. In that day, women just were not accepted as lasix online surgeons. KATIE HAFNER. In 1926, when Dorothy Andersen graduated medical school, there were practically no female surgeons.

In fact, until 1975, the American College of Surgeons admitted five or lasix online fewer women a year. So Dorothy Andersen settled for a career in pathology. In the medical community, pathologists sometimes have a reputation for not being people people, of working with dead bodies and lifeless organs for a reason. Pathologists seldom lasix online see living patients, except to do certain biopsies. But Dorothy Andersen was a different kind of pathologist.

Here’s Scott Baird again. SCOTT lasix online BAIRD. She felt the suffering of others, and she did her best to try to minimize that whenever possible. It’s difficult to advance the care and advance medical knowledge at the same time that you're providing the sympathetic care she provided for all of them. KATIE HAFNER lasix online.

In the 1940s, cystic fibrosis was so new that parents had trouble finding physicians who knew much about it or who were even willing to take on a new cystic fibrosis patient, especially when the prognosis was so grim and death so swift. At the time, it was rare for patients with CF to live past five. But word lasix online started to spread that there was this doctor in New York City who knew all about the disease. Desperate parents began bringing their kids to Dr. Andersen from all over the place.

Here’s Doris Tulcin, whose daughter lasix online was diagnosed with cystic fibrosis in 1953. DORIS TULCIN. And after taking her to many, many different doctors who could not figure out what was wrong, we went through an agonizing three months until a very dear friend of my mother’s, who was a nurse, read in a nurse’s magazine about a Dorothy Andersen and cystic fibrosis. KATIE HAFNER lasix online. So Doris Tulcin took her daughter to see Dr.

Andersen. DORIS TULCIN lasix online. She was a dowdy-looking thing, with a bun in the back of her head, no makeup. She had on a lab coat. You could tell she was a big smoker because she smelled of cigarettes, but she was very kind lasix online.

And you knew that she really, really cared about what she was doing for these kids. KATIE HAFNER. Okay, so lasix online let’s see. Dowdy--by the way, I can’t think of a single time I heard a man described as “dowdy”--brilliant, a heavy smoker, great with a microscope, but what else?. We knew she’d grown up in North Carolina and Vermont and she’d been orphaned as a teen.

She never married and dedicated her lasix online life to her work. And that piece in The Lancet that I mentioned earlier, it said this. She described herself as a “rugged individualist.” And I knew she earned her bachelor's degree in Chemistry and Zoology at Mount Holyoke College, a women’s college in South Hadley, Massachusetts. LESLIE lasix online FIELDS. My name is Leslie Fields, and I am the head of archives and special collections at Mt.

Holyoke College. KATIE HAFNER lasix online. The school keeps biographical files on many of its graduates, organized by graduating year. Dorothy Andersen entered Mt. Holyoke in 1918, the year the Spanish flu lasix hit the country, and she graduated in 1922, not even two years after women got lasix online the right to vote.

LESLIE FIELDS. So some students and alums might simply have a single biographical sheet that has a little bit of factual information about them. And others might have 50 lasix online boxes of correspondence. So hers is on the smaller side. So it is two thick folders.

That’s the extent of lasix online what we have in her biographical material. They’re primarily made up of professional documents and administrative records from the college perspective on her. So we actually, we don’t have her personal papers here. KATIE HAFNER lasix online. The alumni questionnaires that asked about marriage and children were left blank.

LESLIE FIELDS. But her education section about graduate lasix online school and becoming a doctor, that’s in great detail. And there’s even a question about publications, and she usually writes something like, “Over 80 publications, too numerous to list here.” KATIE HAFNER. That part makes sense. In terms lasix online of career accomplishments, Dorothy Andersen fulfilled the Mt.

Holyoke promise. The school was a bastion of science education from the day in 1837 when Mary Lyon, a devoutly religious educator and self-taught chemistry professor, opened its doors. And much lasix online was expected of Mt. Holyoke’s students. LESLIE FIELDS.

There is an expectation by Mary Woolley.. lasix online. KATIE HAFNER. Who was the president when Dorothy Andersen was a student. LESLIE lasix online FIELDS. ...that they are going to do something with their lives, they’re going to serve the world in some way.

Helping others in some way was a real focus of the college community at that time. And then they’re sort lasix online of launched into the world, and I think for some of them, it looks like that was hard because maybe the world wasn’t quite ready to accept them as professional women in some ways. So out there, real options might have been more limited. KATIE HAFNER. I couldn’t lasix online go to Mt.

Holyoke in person because of hypertension medications. So as I’m perusing the 80-page PDF that Leslie Field’s colleague has sent, something catches my eye. It’s a questionnaire Dorothy Andersen filled lasix online out in 1944. There in the middle of the back page is this question. €œName and address of person most likely always to know your whereabouts”.

Dorothy Andersen put a lasix online question mark. Here’s this woman, 43 years into her life, and when asked, “Who will always know where you are?. € she didn’t have an answer. And it gets me to wondering, What does it mean to live a life filled with accomplishments and not to lasix online be able to answer that basic question?. Who is going to preserve the memory of what you’ve done and who you were?.

I think this is how large pieces of a life go missing. They slip through the cracks lasix online of history and they’re lost. It means that big swaths of your life may be punctuated with a question mark. Most of Dorothy Andersen’s colleagues have died, but there is one…. CELIA ORES lasix online.

Can you put this down and we'd go and pick up doctor Andersen and put her here on the table?. SOPHIE MCNULTY. Oh, the photo? lasix online. Yeah. Yeah, let's go.

Let's go find the photo lasix online. KATIE HAFNER:The people you will be hearing are Sophie McNulty, who’s our associate producer, Michelle Ores, and her mother— CELIA ORES. My name is Celia Ores. I was born in Poland in the town of Dubienka, and we were forced to leave our homes lasix online when Hitler came to our home. KATIE HAFNER.

Dr. Ores eventually came to the US and went on to be a prominent lasix online pediatrician herself. She’s in her nineties now, and she worked with Dorothy Andersen at Babies Hospital in the early 1960s. Celia Ores completely revered Dr. Andersen.

And it turns out that she even keeps a framed photograph of Dr. Anderson on a shelf right next to her bed. MICHELLE ORES. I have it here, mom. SOPHIE MCNULTY.

Michelle has them. CELIA ORES. Oh, okay. MICHELLE ORES. I have the two photos.

I have the one of Dorothy. And the one of you in Switzerland in medical school. CELIA ORES. It’s um, this is in the country, she was. SOPHIE MCNULTY.

This photograph?. CELIA ORES. She had a country home and students were invited for groups. It’s a huge forest and it was family. KATIE HAFNER.

The black and white photograph was taken in the early 1960’s, just a year or so before Dr. Andersen died. She looks tough, as many people say she was, but also kind. The photo stayed on the table during the interview with Dr. Ores.

And once in a while, while she was talking, she would glance over at it. CELIA ORES. She was my supporter there. No man could come to me while she was alive and there and tell me any negative thing because they would be killed by her. So she was my protector and my guide, and she gave me the courage to do a lot of things.

KATIE HAFNER. Dr. Ores stopped practicing medicine more than a decade ago, and her daughter Michelle has her mother’s papers stored in her basement in Connecticut. MICHELLE ORES. We’re going down to the basement, where my mother kept her medical files.

KATIE HAFNER. At first, it looks like we’ve hit a dead end. SOPHIE MCNULTY. It looks like most of these boxes are just from her private practice and continuing work at Columbia. KATIE HAFNER.

That’s Sophie again, she’s gone to Connecticut to look through Dr. Ores’s boxes. SOPHIE MCNULTY. I’ll let you know if I find anything. KATIE HAFNER.

Then, a discovery… SOPHIE MCNULTY. Okay, I think I hit the jackpot. I just found two folders titled “Dorothy Andersen.”KATIE HAFNER.

Dr. Collins knows a little about Dorothy Andersen. FRANCIS COLLINS.

I know her as the person who, in 1938, described this disorder, cystic fibrosis of the pancreas. KATIE HAFNER. But he was a bit chagrined to admit, that’s pretty much all he knows.

FRANCIS COLLINS. I don’t know much about her career, her person, as somebody who must have traveled an interesting journey as a woman working in medical research. KATIE HAFNER.

As one of the scientists who isolated the cystic fibrosis gene in 1989, Dr. Collins stood on the shoulders of path-breaking scientists like Dr. Dorothy Andersen.

He is also an outspoken champion of women in science. So if he doesn’t know much about her, who does?. In this episode, we’re going to tackle two mysteries.

The first is the disease itself–cystic fibrosis. In the 1930s, it was a cruel killer of infants that was routinely misdiagnosed—until Dorothy Andersen solved the puzzle. And then we’ll turn to the mystery of Dorothy Andersen herself, an ingenious medical sleuth who left behind very few clues for those of us trying to understand what made her tick.

Dorothy Andersen stood out. She was one of the very few women working as a physician in the first half of the twentieth century. BIJAL TRIVEDI.

In the thirties, women made up only five percent of practicing physicians, so she was a rarity. KATIE HAFNER. That’s Bijal Trivedi, a science journalist whose book, “Breath from Salt,” describes the history of cystic fibrosis.

BIJAL TRIVEDI. Dorothy Andersen had always wanted to practice medicine. She was a determined woman and she wanted to have a career, and settled for becoming a pathologist.

KATIE HAFNER. At the time, there were few options for women with medical degrees–many hospitals wouldn’t hire women, and even if they did, women usually got pigeonholed to specialties like gynecology or psychiatry. In those days, men and women alike often objected to being seen by female physicians, which also led many women to pathology, where doctors rarely interacted with patients.

Pathologists study the nature and cause of disease. And in the 1930’s, one of the only ways to investigate how disease ravaged the body was through autopsies. That’s how it came to pass one day in 1935 that Dr.

Dorothy Andersen stood at a stainless steel table in the basement of Columbia’s Babies Hospital in Washington Heights. Her task was indescribably tragic, but she was all business as she set upon it—to dissect the organs of yet another child who had died. This child was a 3 year old girl.

The girl had come into the hospital a year before... BIJAL TRIVEDI. ...and she looked terrible.

She had a distended belly, skinny limbs, foul, persistent diarrhea, and she had been diagnosed with celiac disease and sent home. But there she was a year later, and she was dead. And so Dorothy Andersen started doing this autopsy and slowly began to realize that this was not celiac disease.

KATIE HAFNER. At the time, it was common for children with cystic fibrosis to be misdiagnosed with celiac disease– A lot of people are sensitive to gluten, and a subset of those people have full-blown celiac disease—an immune reaction to wheat and rye that inflames the intestine and can cause severe GI symptoms. This inflammation is also a symptom of cystic fibrosis.

Of course these are two very different diseases with very different treatments and outcomes. But, at the time, the misdiagnosis was understandable. And there were two reasons for it.

First, they had the GI symptoms in common. That was number one. And number two.

Frequent pneumonias and breathing problems were misattributed to the malnutrition that accompanies celiac disease instead of a problem with the lungs. So as Dorothy Andersen began examining the organs of the 3-year-old child... BIJAL TRIVEDI.

...she realized that there were a lot of differences, and the most profound differences were in the lungs. And as she started to look into the airways of the lungs, she saw that they were, they were plugged full of mucus, thick, sticky, green mucus. But when she cut into the pancreas, I mean, she could barely get the scalpel in.

And when she sort of tried to cut, she heard a scraping sound as if she were cutting through grit or sand. All she could see was this fibrous, tough material, completely enveloping the whole gland. So, you know, she knew this was something very, very different.

WILLIAM SKACH. You know, with Dorothy Anderson's description of the actual entity of CF, it became clear that it was multi-system. KATIE HAFNER That’s Dr.

William Skach, the outgoing Chief Scientific Officer of the Cystic Fibrosis Foundation. WILLIAM SKACH. It did not just affect the lungs or the pancreas, but affected multiple tissues.

KATIE HAFNER. To understand just how cystic fibrosis affects multiple systems, we need to take a brief medical excursion into the body–and specifically, its tubes. Bear with me.

One of the miracles of our construction is that we’re filled with tubes–conduits that move stuff from one place to another. Perhaps the most familiar ones are blood vessels–an intricate arborized network of miles of tubes that circulate blood. Block these tubes–most commonly by a clot–and the tissue at the far end dies.

When it’s the brain, it’s a stroke. When it’s the heart itself, it’s a heart attack. The lungs also have blood vessels, but the most important tubes in and out of the lungs are the ones that allow for oxygen to come in and carbon dioxide to come out.

If those tubes are blocked, we can’t live. The pancreas also has tubes–the main one being the pancreatic duct. The miracle here is that the pancreas, which is producing digestive enzymes capable of breaking down a piece of steak in our intestine, doesn’t digest itself.

The reason is that the corrosive enzymes flow into these tubes, and from there they enter the intestines. But block these tubes and the juices back up into the pancreas itself, to devastating effect. What Dorothy Andersen discovered was that the primary problem with these patients was very different from what causes celiac disease.

And so Dorothy Andersen’s discovery was that the lungs and pancreas shared the same fatal problem—that the real issue wasn’t inflammation in the wall of the intestine. It was the clogging of the tubes in the pancreas and the lungs. Something was gumming up the tubes like molasses in a straw.

Again, Bijal Trivedi. BIJAL TRIVEDI. With this disease, patients get persistent lung s that destroy lung tissue and limit the ability to breathe.

This thick mucus also builds up in their airways, so they can’t actually inhale properly. They can’t take a full breath and breathe deeply. They can’t laugh properly, because they don’t have the air to laugh.

SARA KOMINSKY. It feels like you’re suffocating to death. And at the point before my first lung transplant, I couldn’t even walk across the room, even on oxygen, without gasping and feeling like I’d… throw up because it took so much effort.

KATIE HAFNER. That was Sara Kominsky who’s 50 now, describing what it’s like to have cystic fibrosis. Next is Malory Woodruff, who’s in her mid-30s.

MALLORY WOODRUFF. I started getting winded a lot easier. I started producing more mucus, cough, coughing up plugs.

The plugs started getting, you know, thicker and greener, yuckier. And then, by the time I was in college...it was really hard to get to class, honestly. SARA KOMINSKY.

All the other CF patients I met during my childhood and young adulthood, by the time I was in my mid-20s early-30s, all of them had passed away. KATIE HAFNER. In the 1970s and 80s, when Sara and Mallory were born, CF patients rarely lived past their teens.

But their prospects are improving. Today, the life expectancy for CF patients is around 50. And a breakthrough drug called Trikafta was approved by the FDA just two years ago.

It’s very expensive, but Trikafta promises to dramatically improve this prognosis and the patients’ quality of life. Dorothy Andersen wasn’t setting out to identify an entirely different disease. But she kept an open mind, open enough to process surprising findings and consider the possibility that the medical community’s prior understanding was just plain wrong.

BRIAN O’SULLIVAN. Well, I have Dorothy Andersen’s papers right here on my desk. In fact, I keep them in a bag that I bring back and forth to work pretty much all the time.

KATIE HAFNER. That’s Brian O’Sullivan, a pediatric pulmonologist who teaches at the Geisel School of Medicine at Dartmouth. BRIAN O’SULLIVAN.

And the first is one from the American Journal of Diseases of Childhood in 1938. And it’s title is “Cystic Fibrosis of the Pancreas and Its Relation to Celiac Disease. A Clinical and Pathological Study,” by Dorothy H.

Andersen, MD, New York. KATIE HAFNER:I first came across Dr. O’Sullivan’s name when he was quoted in a 2014 article in The Lancet, one of the most popular medical journals.

The article was a brief biographical sketch of Dr. Andersen. And it turns out that every year when Brian O’Sullivan lectures to first-year med students about cystic fibrosis...

BRIAN O’SULLIVAN. The disease has obviously been around for millennia. It’s a genetic disease.

KATIE HAFNER. He makes a point of paying tribute to this key figure in the history of the disease. BRIAN O’SULLIVAN.

I want to take a minute to call out Dorothy Andersen. This is a woman who, you know, in the 1920’s, late twenties, early thirties when she was going to medical school, there weren’t a lot of women in medical school. And it’s funny, I’m looking out at the audience now, and it’s almost all women.

But it was very different in the thirties. KATIE HAFNER. That 1938 paper he carries with him at all times was 50 pages long and written by a single author, which would be unheard of in today’s world of publishing, where there are usually at least half a dozen, and sometimes hundreds of authors on a paper.

BRIAN O’SULLIVAN. There’s the old saying, “Luck favors the prepared mind.” The luck was that she was in a position where she saw some children, unfortunately, who had died of this problem. The prepared mind is Dorothy.

I mean, she’s just brilliant, and she put this puzzle together. And so she recognized that she was seeing a group of children who had some of the hallmarks of celiac disease but on autopsy had very different problems. KATIE HAFNER.

That 50 page paper she published reviewed 20 cases from Dr. Andersen’s own institution and many more from other places, in an era where there was no Google Scholar. BRIAN O’SULLIVAN.

She must have spent hours in the library finding these articles and then writing to other physicians and seeing if she could get their slides from autopsies to be able to compare to what she was seeing. KATIE HAFNER. She reviewed hundreds of pathology slides from other children believed to have died from celiac disease, until...

BRIAN O’SULLIVAN. She really spelled out that she was identifying a completely different disease, and it was the first time it really was recognized as a separate entity. KATIE HAFNER.

And she didn’t stop there. After recognizing cystic fibrosis as something different, Dorothy Andersen went back to work, trying to understand as much as she could about the disease. And she started racking up a lot of firsts.

SCOTT BAIRD. She was the first to diagnose CF in a living patient, the first to emphasize diet and pancreatic enzyme replacement therapy in CF, the first to successfully treat pulmonary in CF with antibiotics, and the first to recognize that CF was a hereditary disease expressed in the manner of a recessive trait. KATIE HAFNER.

Scott Baird is a pediatric critical care doctor at Columbia University Medical Center and he’s seen scores of CF patients throughout his clinical career. Like Dorothy Andersen before him, Dr. Baird has spent the bulk of his professional life at Columbia, so there’s a kinship there.

And Scott Baird, it turns out, isn’t just a fan of Dr. Andersen’s work. He’s on a quest to fill in the details of her life.

SCOTT BAIRD. Dorothy Andersen, who never was specifically trained in pathology, never specifically trained in pediatrics, became a world-class pathologist, a world-class pediatrician, and clearly was a world-class researcher, somebody who was able to define and determine what might be associated with disease in patients, and who was able to push the boundaries. KATIE HAFNER.

Coming up, we’ll start to untangle more about this mysterious scientist. I’m Katie Hafner and this is Lost Women of Science. (AD) KATIE HAFNER.

So now that we appreciate what Dorothy Andersen did, let’s try to unravel another mystery. Who she was. Dorothy Hansine Anderson graduated from Johns Hopkins Medical School in 1926, one of only 5 women in her class.

But Hopkins was well ahead of its time. When the medical school opened in 1893, there were three women admitted to the first class. Harvard Medical School wouldn’t officially admit its first women until 1945!.

Here’s Brian O’Sullivan again. BRIAN O’SULLIVAN:. Um, following that she went to Rochester and did an internship and then she wanted to become a surgeon.

In that day, women just were not accepted as surgeons. KATIE HAFNER. In 1926, when Dorothy Andersen graduated medical school, there were practically no female surgeons.

In fact, until 1975, the American College of Surgeons admitted five or fewer women a year. So Dorothy Andersen settled for a career in pathology. In the medical community, pathologists sometimes have a reputation for not being people people, of working with dead bodies and lifeless organs for a reason.

Pathologists seldom see living patients, except to do certain biopsies. But Dorothy Andersen was a different kind of pathologist. Here’s Scott Baird again.

SCOTT BAIRD. She felt the suffering of others, and she did her best to try to minimize that whenever possible. It’s difficult to advance the care and advance medical knowledge at the same time that you're providing the sympathetic care she provided for all of them.

KATIE HAFNER. In the 1940s, cystic fibrosis was so new that parents had trouble finding physicians who knew much about it or who were even willing to take on a new cystic fibrosis patient, especially when the prognosis was so grim and death so swift. At the time, it was rare for patients with CF to live past five.

But word started to spread that there was this doctor in New York City who knew all about the disease. Desperate parents began bringing their kids to Dr. Andersen from all over the place.

Here’s Doris Tulcin, whose daughter was diagnosed with cystic fibrosis in 1953. DORIS TULCIN. And after taking her to many, many different doctors who could not figure out what was wrong, we went through an agonizing three months until a very dear friend of my mother’s, who was a nurse, read in a nurse’s magazine about a Dorothy Andersen and cystic fibrosis.

KATIE HAFNER. So Doris Tulcin took her daughter to see Dr. Andersen.

DORIS TULCIN. She was a dowdy-looking thing, with a bun in the back of her head, no makeup. She had on a lab coat.

You could tell she was a big smoker because she smelled of cigarettes, but she was very kind. And you knew that she really, really cared about what she was doing for these kids. KATIE HAFNER.

Okay, so let’s see. Dowdy--by the way, I can’t think of a single time I heard a man described as “dowdy”--brilliant, a heavy smoker, great with a microscope, but what else?. We knew she’d grown up in North Carolina and Vermont and she’d been orphaned as a teen.

She never married and dedicated her life to her work. And that piece in The Lancet that I mentioned earlier, it said this. She described herself as a “rugged individualist.” And I knew she earned her bachelor's degree in Chemistry and Zoology at Mount Holyoke College, a women’s college in South Hadley, Massachusetts.

LESLIE FIELDS. My name is Leslie Fields, and I am the head of archives and special collections at Mt. Holyoke College.

KATIE HAFNER. The school keeps biographical files on many of its graduates, organized by graduating year. Dorothy Andersen entered Mt.

Holyoke in 1918, the year the Spanish flu lasix hit the country, and she graduated in 1922, not even two years after women got the right to vote. LESLIE FIELDS. So some students and alums might simply have a single biographical sheet that has a little bit of factual information about them.

And others might have 50 boxes of correspondence. So hers is on the smaller side. So it is two thick folders.

That’s the extent of what we have in her biographical material. They’re primarily made up of professional documents and administrative records from the college perspective on her. So we actually, we don’t have her personal papers here.

KATIE HAFNER. The alumni questionnaires that asked about marriage and children were left blank. LESLIE FIELDS.

But her education section about graduate school and becoming a doctor, that’s in great detail. And there’s even a question about publications, and she usually writes something like, “Over 80 publications, too numerous to list here.” KATIE HAFNER. That part makes sense.

In terms of career accomplishments, Dorothy Andersen fulfilled the Mt. Holyoke promise. The school was a bastion of science education from the day in 1837 when Mary Lyon, a devoutly religious educator and self-taught chemistry professor, opened its doors.

And much was expected of Mt. Holyoke’s students. LESLIE FIELDS.

There is an expectation by Mary Woolley... KATIE HAFNER. Who was the president when Dorothy Andersen was a student.

LESLIE FIELDS. ...that they are going to do something with their lives, they’re going to serve the world in some way. Helping others in some way was a real focus of the college community at that time.

And then they’re sort of launched into the world, and I think for some of them, it looks like that was hard because maybe the world wasn’t quite ready to accept them as professional women in some ways. So out there, real options might have been more limited. KATIE HAFNER.

I couldn’t go to Mt. Holyoke in person because of hypertension medications. So as I’m perusing the 80-page PDF that Leslie Field’s colleague has sent, something catches my eye.

It’s a questionnaire Dorothy Andersen filled out in 1944. There in the middle of the back page is this question. €œName and address of person most likely always to know your whereabouts”.

Dorothy Andersen put a question mark. Here’s this woman, 43 years into her life, and when asked, “Who will always know where you are?. € she didn’t have an answer.

And it gets me to wondering, What does it mean to live a life filled with accomplishments and not to be able to answer that basic question?. Who is going to preserve the memory of what you’ve done and who you were?. I think this is how large pieces of a life go missing.

They slip through the cracks of history and they’re lost. It means that big swaths of your life may be punctuated with a question mark. Most of Dorothy Andersen’s colleagues have died, but there is one….

CELIA ORES. Can you put this down and we'd go and pick up doctor Andersen and put her here on the table?. SOPHIE MCNULTY.

Let's go find the photo. KATIE HAFNER:The people you will be hearing are Sophie McNulty, who’s our associate producer, Michelle Ores, and her mother— CELIA ORES. My name is Celia Ores.

I was born in Poland in the town of Dubienka, and we were forced to leave our homes when Hitler came to our home. KATIE HAFNER. Dr.

Ores eventually came to the US and went on to be a prominent pediatrician herself. She’s in her nineties now, and she worked with Dorothy Andersen at Babies Hospital in the early 1960s. Celia Ores completely revered Dr.

Andersen. And it turns out that she even keeps a framed photograph of Dr. Anderson on a shelf right next to her bed.

MICHELLE ORES. I have it here, mom. SOPHIE MCNULTY.

MICHELLE ORES. I have the two photos. I have the one of Dorothy.

And the one of you in Switzerland in medical school. CELIA ORES. It’s um, this is in the country, she was.

SOPHIE MCNULTY. This photograph?. CELIA ORES.

She had a country home and students were invited for groups. It’s a huge forest and it was family. KATIE HAFNER.

The black and white photograph was taken in the early 1960’s, just a year or so before Dr. Andersen died. She looks tough, as many people say she was, but also kind.

The photo stayed on the table during the interview with Dr. Ores. And once in a while, while she was talking, she would glance over at it.

CELIA ORES. She was my supporter there. No man could come to me while she was alive and there and tell me any negative thing because they would be killed by her.

So she was my protector and my guide, and she gave me the courage to do a lot of things. KATIE HAFNER. Dr.

Ores stopped practicing medicine more than a decade ago, and her daughter Michelle has her mother’s papers stored in her basement in Connecticut. MICHELLE ORES. We’re going down to the basement, where my mother kept her medical files.

KATIE HAFNER. At first, it looks like we’ve hit a dead end. SOPHIE MCNULTY.

It looks like most of these boxes are just from her private practice and continuing work at Columbia. KATIE HAFNER. That’s Sophie again, she’s gone to Connecticut to look through Dr.

Ores’s boxes. SOPHIE MCNULTY. I’ll let you know if I find anything.

KATIE HAFNER. Then, a discovery… SOPHIE MCNULTY. Okay, I think I hit the jackpot.

I just found two folders titled “Dorothy Andersen.”KATIE HAFNER. In our next episode of LWOS, we’ll dig through the boxes and see what we can find. [MUSIC] This has been Lost Women of Science.

Thanks to everyone who made this initiative happen, including my co-executive producer Amy Scharf, Senior Producer Tracy Wahl, associate producer Sophie McNulty, composer Elizabeth Younan, and technical director Abdullah Rufus. We’re grateful to Jane Grogan, Mike Fung, Susan Kare, Scott Baird, Brian McTear, Alison Gwinn, Bob Wachter, Nora Mathison, Robin Linn, Matt Engle, Cathie Bennett Warner, Maria Klawe, Jeannie Stivers, Nikaline McCarley, Bijal Trivedi, and our interns, Kylie Tangonan, Baiz Hoen and Ella Zaslow. Thanks also to the Mount Holyoke archives for helping with our search, to the Cystic Fibrosis Foundation for all their support.

To Paula Goodwin, Nicole Schilling and the rest of the legal team at Perkins Coie, and to Harvey Mudd College, a leader in exemplary STEM education. We’re also grateful to Barnard College, a leader in empowering young women to pursue their passions in STEM as well as the arts, for support during the Barnard Year of Science.

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