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04 September, kamagra for sale find more 2020. Following a comprehensive search, the Board of the Australian Digital Health Agency announced today that Ms Amanda Cattermole PSM will be appointed as Chief Executive Officer of the Agency. Ms Cattermole has a long and distinguished history of senior leadership kamagra for sale roles in service delivery in the public sector, leading high performing organisations, while growing customer satisfaction and staff engagement. She also has deep expertise in digital transformation across government and within the health sector.Most recently, Ms Cattermole was Chief Operating Officer of Services Australia with responsibility for budget and financial services, people, governance, audit and risk.

Ms Cattermole was previously the interim CEO of Services Australia and has held Deputy Secretary roles in health service delivery in the Commonwealth and in the Victorian State kamagra for sale Government. Ms Cattermole holds a Master of Laws from Charles Darwin University, a Master of Business Administration from the University of Western Australia and Bachelor Degrees in Law and Commerce from the University of Melbourne.Welcoming Ms Cattermole’s appointment on behalf of the Agency, Board Chair Dr Elizabeth Deveny said “Amanda Cattermole is held in the highest regard across the public service and health sector and will bring a depth of knowledge and capability to the role of CEO at a time when digital health has never been more important. The Board has appointed a leader who is deeply skilled, committed to improving the health of all Australians and who understands the importance kamagra for sale of digital innovation in better connecting Australia’s healthcare system.”The Hon Greg Hunt, Minister for Health, said “I am pleased to welcome Ms Cattermole and look forward to working closely together to drive technology in healthcare as the need has never been greater.”The Board of the Agency also acknowledged the invaluable leadership of Ms Bettina McMahon, who has acted as CEO since February this year. €œThe Board of the Agency would like to thank Ms McMahon for her leadership, dedication and commitment, and wishes her the best for the future.”Ms Cattermole will commence on Tuesday 29 September.Media contactAustralian Digital Health Agency Media TeamMobile.

0428 772 421Email. [email protected] About the Australian Digital Health AgencyThe Agency is kamagra for sale tasked with improving health outcomes for all Australians through the delivery of digital healthcare systems, and implementing Australia’s National Digital Health Strategy – Safe, Seamless, and Secure. Evolving health and care to meet the needs of modern Australia in collaboration with partners across the community. The Agency is the System Operator of My Health kamagra for sale Record, and provides leadership, coordination, and delivery of a collaborative and innovative approach to utilising technology to support and enhance a clinically safe and connected national health system.

These improvements will give individuals more control of their health and their health information, and support healthcare providers to deliver informed healthcare through access to current clinical and treatment information. Further information kamagra for sale. Www.digitalhealth.gov.auMedia release - Australian Digital Health Agency CEO announced.docx 66KB)Media release - Australian Digital Health Agency CEO announced.pdf (191KB)By operation of the Public Governance, Performance and Accountability (Establishing the Australian Digital Health Agency) Rule 2016, on 1 July 2016, all the assets and liabilities of NEHTA will vest in the Australian Digital Health Agency. In this website, on and from 1 July 2016, all references to "National E-Health Transition Authority" kamagra for sale or "NEHTA" will be deemed to be references to the Australian Digital Health Agency.

PCEHR means the My Health Record, formerly the "Personally Controlled Electronic Health Record", within the meaning of the My Health Records Act 2012 (Cth), formerly called the Personally Controlled Electronic Health Records Act 2012 (Cth). Website Accessibility Copyright ©2015-2020 Australian Digital Health Agency.

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About Navigating Aging To send comments or ideas for this column, contact us.Navigating Aging focuses on medical issues and kamagra 100mg online advice associated with aging and end-of-life care, helping America's 45 million seniors and their families navigate the health care system.Judith Graham, KHN contributing columnist, has written for The New York Times, Chicago Tribune, STAT News, The Washington Post and the Journal of the American Medical Association, among others. She was nominated for a Pulitzer Prize for a series on defective pacemakers by The Denver kamagra 100mg online Post. This story also ran on CNN. This story can be republished for free (details). A tidal wave of grief and loss has rolled through long-term care facilities as the erectile dysfunction kamagra has killed more than 91,000 residents and staffers — nearly 40% of recorded erectile dysfunction treatment deaths in the U.S.And it’s not over. Facilities are bracing for further shocks as erectile dysfunction cases rise across the country.Workers are already emotionally drained and exhausted after staffing the front lines — and putting themselves at significant risk — since kamagra 100mg online March, when the kamagra took hold. And residents are suffering deeply from losing people they once saw daily, the disruption of routines and being cut off from friends and family.

Email Sign-Up Subscribe to California Healthline’s free Daily kamagra 100mg online Edition. In response, nursing homes and assisted living centers are holding memorials for people who’ve died, having chaplains and social workers help residents and staff, and bringing in hospice providers to offer grief counseling, among other strategies. More than 2 million vulnerable older adults live in these facilities.“Everyone is aware that this is a stressful, traumatic kamagra 100mg online time, with no end in sight, and there needs to be some sort of intervention,” said Barbara Speedling, a long-term care consultant working on these issues with the American Health Care Association and National Center for Assisted Living, an industry organization.Connie Graham, 65, is corporate chaplain at Community Health Services of Georgia, which operates 56 nursing homes. For months, he’s been holding socially distant prayer services in the homes’ parking lots for residents and staff members.“People want prayers for friends in the facilities who’ve passed away, for relatives and friends who’ve passed away, for the safety of their families, for the loss of visitation, for healing, for the strength and perseverance to hold on,” Graham said.Central Baptist Village, a Norridge, Illinois, nursing home, held a socially distanced garden ceremony to honor a beloved nurse who had died of erectile dysfunction treatment. €œOur social service director made a wonderful collage of photos and left Post-its so everyone could write a memory” before delivering it to the nurse’s wife, said Dawn Mondschein, the nursing home’s chief executive officer.“There’s a steady level of anxiety, with spikes of frustration and depression,” Mondschein said of staff members and residents.Vitas Healthcare, a hospice provider in 14 states and the District of Columbia, has created occasional “virtual blessing services” on Zoom for staffers at nursing homes and assisted living centers kamagra 100mg online.

€œWe thank them for their service and a chaplain gives words of encouragement,” said Robin Fiorelli, Vitas’ senior director of bereavement and volunteers.Vitas has also been holding virtual memorials via Zoom to recognize residents who’ve died of erectile dysfunction treatment. €œA big part of that service is giving other residents an opportunity to share their memories and honor those they’ve lost,” Fiorelli said.On Dec kamagra 100mg online. 6, Hospice Savannah in Georgia is going one step further and planning a national online broadcast of its annual “Tree of Light” memorial, with grief counselors who will offer healing strategies. During the service, candles will be lit and a moment of silence observed in remembrance of people who’ve died.“Grief has become an urgent mental health issue, and we hope this will help begin the healing process for people who haven’t kamagra 100mg online been able to participate in rituals or receive the comfort and support they’d normally have gotten prior to erectile dysfunction treatment,” said Kathleen Benton, Hospice Savannah’s president and chief executive officer.But these and other attempts are hardly equal to the extent of anguish, which has only grown as the kamagra stretches on, fueling a mental health crisis in long-term care.“There is a desperate need for psychological services,” said Toni Miles, a professor at the University of Georgia’s College of Public Health and an expert on grief and bereavement in long-term care settings. She’s created two guides to help grieving staffers and residents and is distributing them digitally to more than 400 nursing homes and 1,000 assisted living centers in the state.A recent survey by Altarum, a nonprofit research and consulting firm, highlights the hopelessness of many nursing home residents.

The survey asked 365 people living in nursing homes about their experiences in kamagra 100mg online July and August.“I am completely isolated. I might as well be buried already,” one resident wrote. €œThere is no hope,” another said kamagra 100mg online. €œI feel like giving up. €¦ No emotional support nor mental health support kamagra 100mg online is available to me,” another complained.Inadequate mental health services in nursing homes have been a problem for years.

Instead of counseling, residents are typically given medications to ease symptoms of distress, said David Grabowski, a professor of health care policy at Harvard Medical School who has published several studies on this topic.The situation has worsened during the kamagra as psychologists and social workers have been unable to enter facilities that limited outsiders to minimize the risk of viral transmission.“Several facilities didn’t consider mental health professionals ‘essential’ health care providers, and many of us weren’t able to get in,” said Lisa Lind, president of Psychologists in Long-Term Care. Although some facilities switched to tele-mental health services, kamagra 100mg online staff shortages have made those hard to arrange, she noted.Fewer than half of nursing home staffers have health insurance, and those who do typically don’t have “minimal” access to mental health services, Grabowski said. That’s a problem because “there’s a real fragility right now on the part of the workforce.”Colleen Frankenfield, president and chief executive officer of Lutheran Social Ministries of New Jersey, said what staffers need most of all is “the ability to vent and to have someone comfort them.” She recalls a horrible day in April, when four residents died in less than 24 hours at her organization’s continuing care retirement community in northern New Jersey, which includes an assisted living facility and a nursing home.“The phone rang at 1 a.m. And all I heard on the other end was an administrator, kamagra 100mg online sobbing,” she remembered. €œShe said she felt she was emotionally falling apart.

She felt like she was responsible kamagra 100mg online for the residents who had died, like she had let them down. She just had to talk about what she was experiencing and cry kamagra 100mg online it out.”Although Lutheran Social Ministries has been free of erectile dysfunction treatment since the end of April, “our employees are tired — always on edge, always worried,” Frankenfield said. €œI think people are afraid and they need time to heal. At the end of the day, all we can really do is stand with them, listen to them and support them in whatever way we kamagra 100mg online can.”Coming Monday. The Navigating Aging column will look at the grief faced by long-term care workers as erectile dysfunction treatment cases and deaths mount.Join Judith Graham for a Facebook Live event on grief and bereavement during the erectile dysfunction kamagra on Monday, Nov.

16, at kamagra 100mg online 1 p.m. ET. You can watch the conversation here and submit questions in advance here.We’re eager to hear from readers about questions you’d like answered, problems kamagra 100mg online you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips. This story was produced by Kaiser Health News, an editorially independent program kamagra 100mg online of the Kaiser Family Foundation.

Correction. This story was updated kamagra 100mg online on Nov. 13 at 4:30 p.m. PT to make clear that the kamagra 100mg online Hospice Savannah’s “Tree of Light” memorial will be its first national ceremony. This story earlier suggested that past ceremonies had also been webcast nationally.

Judith Graham kamagra 100mg online. khn.navigatingaging@gmail.com, @judith_graham Related Topics Aging Mental Health Navigating Aging Long-Term CareThe night before I chopped off my hair, I got nervous.This decision felt bigger than me, given all the weight that Black women’s hair carries. But after three months of wearing hats and scarves in a kamagra when trips to the hairdresser felt unsafe, I walked into a salon emotionally exhausted but ready to finally see my kamagra 100mg online natural hair.I thought a few tears would fall, but, as the last of my chemically straightened hair floated to the floor like rain, I felt cleansed. Free. I laughed hysterically as I drove away from the salon.Friends and kamagra 100mg online family cheered me on virtually, but my father quietly worried about my decision.

My dad grew up in the Jim Crow South, where many women straightened their hair to land jobs, husbands and respect. Before my big chop, he never said much about my hair beyond the occasional compliment, which is why I was surprised when he issued a warning.“Watch kamagra 100mg online it out there. Your hair is cut now,” he blurted when he saw me walking out of the house.My mother heard him but remained silent. She had her kamagra 100mg online own set of concerns. She was worried about me looking less professional.

Email Sign-Up Subscribe to California kamagra 100mg online Healthline’s free Daily Edition. I also had to help my now 4-year-old daughter understand why I decided to go natural. We’ve watched kamagra 100mg online the animated “Hair Love” a million times. We’ve read books like “Happy Hair” kamagra 100mg online by Mechal Renee Roe, “I Love My Hair!. € by Natasha Anastasia Tarpley and my personal favorite, “Don’t Touch My Hair!.

€ by Sharee Miller.Still, my daughter had a hard time adjusting to my new haircut, often kamagra 100mg online asking when I planned to get my hair styled again. She preferred my extensions, saying she thought I looked more like a princess that way. I gently explained that my hair is a style — and the kamagra 100mg online one I choose — even if it’s not long and straight.My family’s emotions about my hair left me tangled.Of course, the styling of Black hair has been fraught for centuries. The CROWN Act, which passed the U.S. House in September and is now pending in the Senate, is intended to protect Black people from discrimination in schools, housing and employment kamagra 100mg online based on their hairstyle.

But such a law, even if passed, cannot stop bigotry, bullets and the emotional battle that comes with being a Black woman in America as seen through something as simple as our hair.I hadn’t considered talking to my daughter about how hair could affect her personal safety until my father broke his silence. A haircut shouldn’t influence your life expectancy.On the night of my haircut, I drove to the kamagra 100mg online store more aware of how others would perceive my new look. My father, however, was more worried about my safety because my silhouette could possibly be mistaken for a Black man’s frame.We live in the Midwest, just outside St. Louis, where natural kamagra 100mg online hair still makes a statement for Black women. If my buzz cut made me look more like a Black man, would the cops in our town treat me differently?.

In my dad’s eyes, my femininity increased my chances of making it home safely.His comments also led to a conversation about the intersection kamagra 100mg online between racism and sexism. Without reading the crucial work of scholar Kimberlé Crenshaw and other activists, my father intuitively understood that society has placed Black women in a blind spot, where our gender and our race make us invisible in many ways.But that space isn’t safe, is it?. A Eurocentric feminine hairstyle can’t kamagra 100mg online protect Black women from the many deadly forms of racism.Police officers can see us. Since 2015, at least 48 Black women have been killed by the police. I’m guessing the style of their hair didn’t matter to the officers pulling the triggers kamagra 100mg online.

In the past few years, the #SayHerName campaign has put a spotlight on their killings, but society still pays less attention to the police killings of Black women. While most people have heard of George Floyd, kamagra 100mg online Michael Brown and Breonna Taylor, fewer know about Kathryn Johnston, Korryn Gaines and India Kager.In death and life, our rights and our achievements don’t seem to hold as much weight compared with those of our male counterparts or our white ones. Yet, many Black women go to great lengths to be accepted in this country.In the past few weeks, I’ve listened to other Black women in my life vent about their hair and navigating racism. We’ve shared our fears, hair horror stories and moments of victory kamagra 100mg online. I’ve come to realize that my haircut wasn’t just about changing my style.

It was also about reclaiming my crown after years of letting society control it. This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Cara Anthony. canthony@kff.org, @CaraRAnthony Related Topics Insight Public Health Race and Health Women's Health.

About Navigating Aging To send comments or ideas for this column, contact us.Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America's 45 million seniors and their families navigate the health care system.Judith Graham, KHN contributing columnist, has written for The New York Times, Chicago Tribune, STAT News, The Washington kamagra for sale Post and the Journal of the American Medical Association, among others. She was nominated for a kamagra for sale Pulitzer Prize for a series on defective pacemakers by The Denver Post. This story also ran on CNN. This story can be republished for free (details). A tidal wave of grief and loss has rolled through long-term care facilities as the erectile dysfunction kamagra has killed more than 91,000 residents and staffers — nearly 40% of recorded erectile dysfunction treatment deaths in the U.S.And it’s not over. Facilities are bracing for further shocks as erectile dysfunction cases rise across the country.Workers are already kamagra for sale emotionally drained and exhausted after staffing the front lines — and putting themselves at significant risk — since March, when the kamagra took hold.

And residents are suffering deeply from losing people they once saw daily, the disruption of routines and being cut off from friends and family. Email Sign-Up kamagra for sale Subscribe to California Healthline’s free Daily Edition. In response, nursing homes and assisted living centers are holding memorials for people who’ve died, having chaplains and social workers help residents and staff, and bringing in hospice providers to offer grief counseling, among other strategies. More than 2 million vulnerable older adults live in these facilities.“Everyone is aware that this is a stressful, traumatic time, with no end in sight, and there needs to be some sort of intervention,” said Barbara Speedling, a long-term care consultant working on these issues with the American Health Care Association and National Center for Assisted Living, an industry organization.Connie Graham, 65, is corporate chaplain at Community kamagra for sale Health Services of Georgia, which operates 56 nursing homes.

For months, he’s been holding socially distant prayer services in the homes’ parking lots for residents and staff members.“People want prayers for friends in the facilities who’ve passed away, for relatives and friends who’ve passed away, for the safety of their families, for the loss of visitation, for healing, for the strength and perseverance to hold on,” Graham said.Central Baptist Village, a Norridge, Illinois, nursing home, held a socially distanced garden ceremony to honor a beloved nurse who had died of erectile dysfunction treatment. €œOur social service director made a wonderful collage of photos and left Post-its so everyone could write a memory” before delivering it to the nurse’s wife, said Dawn Mondschein, the nursing home’s chief executive officer.“There’s a steady level of anxiety, with spikes of frustration and depression,” Mondschein said of staff members and residents.Vitas Healthcare, a hospice provider in 14 states kamagra for sale and the District of Columbia, has created occasional “virtual blessing services” on Zoom for staffers at nursing homes and assisted living centers. €œWe thank them for their service and a chaplain gives words of encouragement,” said Robin Fiorelli, Vitas’ senior director of bereavement and volunteers.Vitas has also been holding virtual memorials via Zoom to recognize residents who’ve died of erectile dysfunction treatment. €œA big part of that service is giving other residents an opportunity to share kamagra for sale their memories and honor those they’ve lost,” Fiorelli said.On Dec.

6, Hospice Savannah in Georgia is going one step further and planning a national online broadcast of its annual “Tree of Light” memorial, with grief counselors who will offer healing strategies. During the service, candles will be lit and a moment of silence observed in remembrance of people who’ve died.“Grief has become an urgent mental health issue, and we hope this will help begin the healing process for people who haven’t been able to participate in rituals or receive the comfort and support they’d normally have gotten kamagra for sale prior to erectile dysfunction treatment,” said Kathleen Benton, Hospice Savannah’s president and chief executive officer.But these and other attempts are hardly equal to the extent of anguish, which has only grown as the kamagra stretches on, fueling a mental health crisis in long-term care.“There is a desperate need for psychological services,” said Toni Miles, a professor at the University of Georgia’s College of Public Health and an expert on grief and bereavement in long-term care settings. She’s created two guides to help grieving staffers and residents and is distributing them digitally to more than 400 nursing homes and 1,000 assisted living centers in the state.A recent survey by Altarum, a nonprofit research and consulting firm, highlights the hopelessness of many nursing home residents. The survey asked 365 people living in kamagra for sale nursing homes about their experiences in July and August.“I am completely isolated.

I might as well be buried already,” one resident wrote. €œThere is no kamagra for sale hope,” another said. €œI feel like giving up. €¦ No emotional support nor mental health support is available kamagra for sale to me,” another complained.Inadequate mental health services in nursing homes have been a problem for years.

Instead of counseling, residents are typically given medications to ease symptoms of distress, said David Grabowski, a professor of health care policy at Harvard Medical School who has published several studies on this topic.The situation has worsened during the kamagra as psychologists and social workers have been unable to enter facilities that limited outsiders to minimize the risk of viral transmission.“Several facilities didn’t consider mental health professionals ‘essential’ health care providers, and many of us weren’t able to get in,” said Lisa Lind, president of Psychologists in Long-Term Care. Although some facilities switched to tele-mental health services, staff shortages have made those hard to arrange, she noted.Fewer than half of nursing home staffers have health insurance, and those who do typically don’t have “minimal” access to mental health kamagra for sale services, Grabowski said. That’s a problem because “there’s a real fragility right now on the part of the workforce.”Colleen Frankenfield, president and chief executive officer of Lutheran Social Ministries of New Jersey, said what staffers need most of all is “the ability to vent and to have someone comfort them.” She recalls a horrible day in April, when four residents died in less than 24 hours at her organization’s continuing care retirement community in northern New Jersey, which includes an assisted living facility and a nursing home.“The phone rang at 1 a.m. And all I heard on the other end was an administrator, sobbing,” she kamagra for sale remembered.

€œShe said she felt she was emotionally falling apart. She felt like she was responsible for the residents who had died, like she had let kamagra for sale them down. She just had to talk about what she was experiencing and cry it out.”Although Lutheran Social Ministries has been free of erectile dysfunction treatment since the end of April, “our employees are kamagra for sale tired — always on edge, always worried,” Frankenfield said. €œI think people are afraid and they need time to heal.

At the end of the day, all we can really do is stand with them, listen to them and support them in whatever kamagra for sale way we can.”Coming Monday. The Navigating Aging column will look at the grief faced by long-term care workers as erectile dysfunction treatment cases and deaths mount.Join Judith Graham for a Facebook Live event on grief and bereavement during the erectile dysfunction kamagra on Monday, Nov. 16, at kamagra for sale 1 p.m. ET.

You can watch the conversation here and submit questions in advance here.We’re kamagra for sale eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips. This story was produced by Kaiser Health kamagra for sale News, an editorially independent program of the Kaiser Family Foundation. Correction.

This story kamagra for sale was updated on Nov. 13 at 4:30 p.m. PT to make clear that the Hospice Savannah’s “Tree of Light” memorial will be kamagra for sale its first national ceremony. This story earlier suggested that past ceremonies had also been webcast nationally.

Judith Graham kamagra for sale. khn.navigatingaging@gmail.com, @judith_graham Related Topics Aging Mental Health Navigating Aging Long-Term CareThe night before I chopped off my hair, I got nervous.This decision felt bigger than me, given all the weight that Black women’s hair carries. But after three months kamagra for sale of wearing hats and scarves in a kamagra when trips to the hairdresser felt unsafe, I walked into a salon emotionally exhausted but ready to finally see my natural hair.I thought a few tears would fall, but, as the last of my chemically straightened hair floated to the floor like rain, I felt cleansed. Free.

I laughed hysterically as I drove kamagra for sale away from the salon.Friends and family cheered me on virtually, but my father quietly worried about my decision. My dad grew up in the Jim Crow South, where many women straightened their hair to land jobs, husbands and respect. Before my big chop, he never said much about my hair beyond the occasional compliment, which is why I kamagra for sale was surprised when he issued a warning.“Watch it out there. Your hair is cut now,” he blurted when he saw me walking out of the house.My mother heard him but remained silent.

She had kamagra for sale her own set of concerns. She was worried about me looking less professional. Email Sign-Up Subscribe to kamagra for sale California Healthline’s free Daily Edition. I also had to help my now 4-year-old daughter understand why I decided to go natural.

We’ve watched kamagra for sale the animated “Hair Love” a million times. We’ve read books like “Happy Hair” by Mechal Renee Roe, “I Love My Hair! kamagra for sale. € by Natasha Anastasia Tarpley and my personal favorite, “Don’t Touch My Hair!. € by Sharee Miller.Still, my daughter had a hard time adjusting to my new haircut, often asking when I planned to get my hair styled again kamagra for sale.

She preferred my extensions, saying she thought I looked more like a princess that way. I gently explained that my hair is a style — and the one I choose — even if it’s not long and straight.My family’s emotions about my hair left me tangled.Of course, the styling of Black hair has been kamagra for sale fraught for centuries. The CROWN Act, which passed the U.S. House in September kamagra for sale and is now pending in the Senate, is intended to protect Black people from discrimination in schools, housing and employment based on their hairstyle.

But such a law, even if passed, cannot stop bigotry, bullets and the emotional battle that comes with being a Black woman in America as seen through something as simple as our hair.I hadn’t considered talking to my daughter about how hair could affect her personal safety until my father broke his silence. A haircut shouldn’t influence your life expectancy.On the night of my haircut, I kamagra for sale drove to the store more aware of how others would perceive my new look. My father, however, was more worried about my safety because my silhouette could possibly be mistaken for a Black man’s frame.We live in the Midwest, just outside St. Louis, where natural hair still makes a statement for Black women.

If my buzz cut made me look more like a Black man, would the cops in our town treat me differently?. In my dad’s eyes, my femininity increased my chances of making it home safely.His comments also led to a conversation about the intersection between racism and sexism. Without reading the crucial work of scholar Kimberlé Crenshaw and other activists, my father intuitively understood that society has placed Black women in a blind spot, where our gender and our race make us invisible in many ways.But that space isn’t safe, is it?. A Eurocentric feminine hairstyle can’t protect Black women from the many deadly forms of racism.Police officers can see us.

Since 2015, at least 48 Black women have been killed by the police. I’m guessing the style of their hair didn’t matter to the officers pulling the triggers. In the past few years, the #SayHerName campaign has put a spotlight on their killings, but society still pays less attention to the police killings of Black women. While most people have heard of George Floyd, Michael Brown and Breonna Taylor, fewer know about Kathryn Johnston, Korryn Gaines and India Kager.In death and life, our rights and our achievements don’t seem to hold as much weight compared with those of our male counterparts or our white ones.

Yet, many Black women go to great lengths to be accepted in this country.In the past few weeks, I’ve listened to other Black women in my life vent about their hair and navigating racism. We’ve shared our fears, hair horror stories and moments of victory. I’ve come to realize that my haircut wasn’t just about changing my style. It was also about reclaiming my crown after years of letting society control it.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Cara Anthony. canthony@kff.org, @CaraRAnthony Related Topics Insight Public Health Race and Health Women's Health.

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We live http://guide.thetrademarkhub.com/no-access/ in kamagra express unprecedented times. But what makes them without parallel is not the current kamagra crisis nor the continued problems facing minorities in our institutions. Rather, it’s that for the first time, the problems of accessibility, rights and freedoms are now invading kamagra express privileged spaces. There can be no ‘getting back to normal’, because ‘normal’ only ever benefited the white, Western, patriarchal, abled and cis ideals. For many, the world is not suddenly on fire.

€¦IntroductionMinecraft is a computer game kamagra express with no specific goals to accomplish. The gameworld consists of three-dimensional (3D) cubes and objects which the player (Steve) can mine and build into infinitely complex (and logically impossible) structures. Steve sometimes encounters other characters (‘mobs’), such as animals and hostile kamagra express creatures. He can ‘spawn’ and destroy them. While it looks like a harmless game of logical construction, it conveys some worryingly delusive ideas about the real world.

The difference between real and imagined structures is at the heart of the age-old debate around categorising mental disorders.Classification in mental health has had various forms kamagra express throughout history. Mack and colleagues set out a history of psychiatric classification beginning in 2600 BC with Egyptian references to melancholia and hysteria. Through the Ancient Greeks with Hippocrates’ kamagra express phrenitis, mania, melancholia, epilepsy, hysteria and Scythian disease. Through the Renaissance period. Through to 19th-century psychiatry featuring Pinel (known as the first psychiatrist), Kraepelin (known for observational classification) and Freud (known for classifying neurosis and psychosis).1Although the history of psychiatric classification identifies some common trends such as the labels ‘melancholia’ and ‘hysteria’ which have survived millennia, the label ‘depression’ is relatively new.

The earliest usage noted by Snaith is from 1899 kamagra express. €˜in simple pathological depression…the patient exhibits a growing indifference to his former pursuits…’.2 Snaith noted that early 20th-century psychiatrists like Adolf Meyer hoped that ‘depression’ would come to encompass a broad category under which descriptions of subtypes would emerge. This did not happen until the middle of kamagra express the 20th century. With the publication of the sixth International Classification of Diseases (ICD) in 1948 and the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 and their subsequent revisions, the latter half of the 20th century has seen depression subtype labels proliferate. In their study of the social determinants of diagnostic labels in depression, McPherson and Armstrong illustrate how the codification of depression subtypes in the latter half of the 20th century has been shaped by the evolving context of psychiatry, including power struggles within the profession, a move to community care and the development of psychopharmacology.3During this period, McPherson and Armstrong describe how subsequent versions of the DSM served as battlegrounds for professional disputes and philosophical quarrels around categorisation of mental disorders.

DSM I and DSM II have been described as products of an American Psychiatric Association dominated by psychoanalytic psychiatrists.4 DSM III and DSM III-R have been described as a radical rejection of psychoanalytic kamagra express thinking, a ‘neo-Kraepelinian revolution’, a reference to the observational descriptive techniques of 19th-century psychiatrist Emil Kraepelin who classified mental disorders into two broad categories. €˜dementia praecox’ and ‘manic-depression’.5 DSM III was seen by some as a turning point in the use of the medical model of mental illness, through provision of specific inclusion and exclusion criteria, and use of field trials and a multiaxial system.6 These latter technocratic additions to psychiatric labelling served to engender a much closer alignment between psychiatry, science and medicine.The codification of mental disorders in manuals has been described by Thomas Schacht as intrinsic to the relationship between science and politics and the way in which psychiatrists gain significant social power by aligning themselves to science.7 His argument drew on Szasz, who saw the mental health establishment as a therapeutic state. Zimbardo, who described kamagra express psychiatric care as a controlling force. And Foucault, who described the categorisation of the mentally ill as a force for isolating ‘the other’. Diagnostic critique has been further developed through a cultural relativist lens in that what Western psychiatrists classify as a depression is constructed differently in other cultures.8 Considering these limitations, some critics have gone so far as to argue that psychiatric diagnostic systems should be abolished.9Yet architects of DSM manuals have worked hard to ensure the technology of classification is regarded as genuine scientific activity with sound roots in philosophy of science.

In their philosophical defence of DSM IV, Allen Frances and colleagues address their critics under the headings ‘nominalism vs realism’, ‘empiricism vs rationalism’ and ‘categorical vs dimensional’.10 The implication is that there are opposing stances kamagra express in which a choice must be made or a middle ground forged by those reasonable enough to recognise the need for pragmatism in the service of clinical utility. The nominalism–realism debate is illustrated using as metaphor three different stances a cricket umpire might take on calling strikes and balls. The discussion sets out two of these as kamagra express extreme views. €˜at one extreme…those who take a reductionistically realistic view of the world’ versus ‘the solipsistic nominalists…might content that nothing exists’. Szasz, who is characterised as holding particularly extreme views, is named as an archetypal solipsist.

There is implied to be a degree of kamagra express arrogance associated with this view in the illustrative example in which the umpire states ‘there are no balls and there are no strikes until I call them’. Frances therefore sets up a means of grouping two kinds of people as philosophical extremists who can be dismissed, while avoiding addressing the philosophical problems they pose.Frances provides little if any justification for the middle ground stance, ‘There are balls and there are strikes and I call them as I see them’, other than to focus on its clinical utility and the lack of clinical utility in the alternatives ‘naïve realism’ and ‘heuristically barren solipsism’. The natural conclusion the reader is invited to reach is kamagra express that a middle ground of a heuristic concept is naturally right because it is not extreme and is naturally useful clinically, without specifying in what way this stance is coherent, resolves the two alternatives, and in what way a heuristic construct that is not ‘real’ can be subject to scientific testing.Similarly, in discussing the ‘categorical vs dimensional’, Frances promotes the ‘prototype approach’. Those holding opposing views are labelled as ‘dualists’ or ‘dichotomisers’. The prototypical approach is again put forward as a clinically useful middle ground.

Illustrations are drawn from natural science kamagra express. €˜a triangle and a square are never the same’, inciting the reader to consider science as value-free. The prototypical approach emerges as a natural solution, yet the authors do not kamagra express address how a diagnostic prototype resolves the issues posed by the two alternatives, nor how a prototype can be subjected to natural science methods.The argument presented here is not a defence of solipsism or dualism. Rather it aims to illustrate that if for pragmatic purposes clinicians and policymakers choose to gloss over the philosophical flaws in classification practices, it is then risky to move beyond the heuristic and apply natural science methods to these constructs adding multiple layers of technocratic subclassification. Doing so is more like playing Minecraft than cricket.

The National Institute for Health and Care Excellence (NICE) guideline kamagra express for depression is taken as an example of the philosophical errors that can follow from playing Minecraft with unsound heuristic devices, specifically subcategories of persistent forms of depression. As well as serving a clinical purpose, diagnosis in medicine is a way of allocating resources for insurance companies and constructing clinical guidelines, which in turn determine rationing within the National Health Service. The consequences for kamagra express recipients of healthcare are therefore significant. Clinical utility is arguably not being served at all and patients are left at risk of poor-quality care.Heterogeneity of persistent depressionAndrea Jobst and colleagues note that ‘because of their chronic clinical course, approximately 40% of CD [chronic depression] patients also fulfil criteria for TRD [treatment resistant depression]…usually defined by the number of non-successful biological treatments’.11 This position is reflected in the DSM VAmerican Psychiatric Association (2013), the European Psychiatric Association (EPA) guidance and the ICD-11(World Health Organisation, 2018), which all use a ‘persistent’ depression category, acknowledging a loosely defined mixed group of long-term, difficult-to-treat depressive conditions, often associated with dysthymia and comorbid common mental disorders, various personality traits and psychosocial disability.In contrast, the NICE 2018 draft guideline separates treatments into those for ‘new episodes’ of depression. €˜further-line’ treatment of depression (equivalent to TRD), CD and ‘depression with co-morbidities’.

The latter kamagra express is subdivided into treatments for ‘complex depression’ and ‘psychotic depression’. These categories and subcategories introduce an unfortunate sense of certainty as though these labels represent real things. An analysis follows of how these definitions play out in kamagra express terms of grouping of randomised controlled trials in the NICE evidence review. Specifically, the analysis reveals the overlap between populations in trials which have been separated into discrete categories, revealing significant limitations to the utility of the category labels.The NICE definition of CD requires trial samples to meet the criteria for major depressive disorder (MDD) for 2 years. Dysthymia and double depression (MDD superimposed on dysthymia) were included.

If 75% of the trial population met these criteria, the kamagra express trial was reviewed in the CD category.12 The definition of TRD (or ‘further-line treatments’) required that the trial sample had demonstrated a ‘limited response to previous treatment’ and randomised to the further-line treatment at this point. If 80% of the trial participants met these criteria, it was reviewed in the TRD category.13 Complex depression was defined as ‘depression co-existing with personality disorder’. To be classed as complex, 51% of trial participants had to have personality disorder (PD).14It is immediately clear from these definitions kamagra express that there is a potential problem with attempting to categorise trial populations into just one of these categories. These populations are likely to overlap, whether or not a trial protocol sets out to explicitly record all of this information. The analysis below will illustrate this using examples from within the NICE review.Cataloguing complexity in trial populationsWithin the category of further-line treatments (TRD), 64 trials were reviewed.

Comparisons within these trials were further kamagra express subcategorised into ‘dose escalation strategies’, ‘augmentation strategies’ and ‘switching strategies’. In drilling down by way of illustration, this analysis considers the 51 trials in the augmentation strategy evidence review. Of these, two were classified by the reviewers as also fulfilling the criteria for CD but were not analysed in the CD category (Study IDs. Fonagy 2015 kamagra express and Kocsis 200915). About half of the trials (23/51) did not report the mean duration of episode, meaning that it is not possible to know what percentage of participants also met the criteria for CD.

Of trials kamagra express that did report episode duration, 17 reported a mean duration longer than 24 months. While the standard deviations varied in size or were unreported, the mean indicates a good likelihood that a significant proportion of the participants across these 51 trials met the criteria for CD.Details of baseline employment, trauma history, suicidality, physical comorbidity, axis I comorbidity and PD (all clinical indicators of complexity, severity and chronicity) were not collated by NICE. For the present analysis, all 51 publications were examined and data compiled concerning clinical complexity in the trial populations. Only 14 of kamagra express 51 trials report employment data. Of those that do, unemployment ranges from 12% to 56% across trial samples.

None of kamagra express the trials report trauma history. About half of the trials (26/51) excluded people who were considered a suicide risk. The others did not.A large proportion of trials (30/51) did not provide any data on axis 1 comorbidity. Of these, 18 did not exclude any diagnoses, while 12 excluded some (but not all) kamagra express disorders. The most common diagnoses excluded were psychotic disorders, substance or alcohol abuse, and bipolar disorder (excluded in 26, 25 and 23 trials, respectively).

Only 7 of 51 trials clearly stated that all kamagra express axis 1 diagnoses were excluded. This leaves only 13 studies providing any data about comorbidity. Of these, 9 gave partial data on one or two conditions, while 4 reported either the mean number of disorders (range 1.96–2.9) or the percentage of participants (range 68.1–96.7) with any comorbid diagnosis (Nierenberg 2003a, Nierenberg 2006, Watkins 2011a, Town 201715).The majority of trials (46/51) did not report the prevalence of PD. Many stated kamagra express PD as an exclusion criterion but without defining a threshold for exclusion. For example, PD could be excluded if it ‘impacted’ the depression, if it was ‘significant’, ‘severe’ or ‘persistent’.

Some excluded certain PDs (such as antisocial or borderline) and not others but without reporting the prevalence kamagra express of those not excluded. In the five trials where prevalence was clear, prevalence ranged from 0% (Ravindran 2008a15), where all PDs were excluded, to 87.5% of the sample (Town 201715). Two studies reported the mean number of PDs. 2.0 (Nierenberg 2003a) and 0.85 (Watkins 2011a15).The majority of trials (43/51) did not report the kamagra express prevalence of physical illness. Many stated illness as an exclusion criterion, but the definitions and thresholds were vague and could be interpreted in different ways.

For example, illness could be excluded if it was ‘unstable’, ‘serious’, ‘significant’, ‘relevant’, or would ‘contraindicate’ or ‘impact’ kamagra express the medication. Of the eight trials reporting information about physical health, there was a wide variation. Four reported prevalence varying from 7.6% having a disability (Eisendrath 201615) to 90.9% having an illness or disability (Town 201715). Four used kamagra express scales of physical health. Two indicating mild problems (Nierenberg 2006, Lavretsky 201115) and two indicating moderately high levels of illness (Thase 2007, Fang 201015).The NICE review also divided trial populations into a dichotomy of ‘more severe’ and ‘less severe’ on the grounds that this would be a clinically useful classification for general practitioners.

NICE applied a bespoke methodology for creating this dichotomy, abandoning validated measure thresholds in order first to generate two ‘homogeneous’ groups to ‘facilitate analysis’, and second to create an algorithm to ‘read across’ different measures (such as the Beck Depression Inventory, the Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Asberg Depression Rating Scale).16 Examining trials which use more than one of these measures reveals kamagra express problems in the algorithm. Of the 51 trials, there are 6 instances in which the study population falls into NICE’s more severe category according to one measure and into the less severe category according to another. In four of these trials, NICE chose the less severe category (Souza 2016, Watkins 2011a, Fonagy 2015, Town 201715). The other two trials were designated kamagra express more severe (Barbee 2011, Dunner 200715). Only 17 of 51 trials reported two or more depression scale measures, leaving much unknown about whether other study populations could count as both more severe and less severe.Absence of knowledge or knowledge of absence?.

A key philosophical error in science is to confuse an kamagra express absence of knowledge with knowledge of absence. It is likely that some of the study populations deemed lacking in complexity or severity could actually have high degrees of complexity and/or severity. Data to demonstrate this may either fall foul of a guideline committee decision to prioritise certain information over other conflicting information (as in the severity algorithm). The information kamagra express may be non-existent as it was not collected. It may be somewhere in the publication pipeline.

Or it may be sitting in a database with a research team that has run out of funds kamagra express for supplementary analyses. Wherever those data are or are not, their absence from published articles does not define the phenomenology of depression for the patients who took part. As a case in point, data from the Fonagy 2015 trial presented at conferences but not published reveal that PD prevalence data would place the trial well within the NICE complex depression category, and that the sample had high levels of past trauma and physical condition comorbidity. The trial also meets the guideline kamagra express criteria for CD according to the guideline’s own appendices.17 Reported axis 1 comorbidity was high (75.2% had anxiety disorder, 18.6% had substance abuse disorder, 13.2% had eating disorder).18 The mean depression scores at baseline were 36.5 on the Beck Depression Inventory and 20.1 on the HRSD (severe and very severe, respectively, according to published cut-off scores). NICE categorised this population as less severe TRD, not CD and not complex.Notes1.

Avram H kamagra express. Mack et al. (1994), “A Brief History of Psychiatric Classification. From the Ancients to kamagra express DSM-IV,” Psychiatric Clinics 17, no. 3.

515–9.2. R. P. Snaith (1987), “The Concepts of Mild Depression,” British Journal of Psychiatry 150, no. 3.

387.3. Susan McPherson and David Armstrong (2006), “Social Determinants of Diagnostic Labels in Depression,” Social Science &. Medicine 62, no. 1. 52–7.4.

Gerald N. Grob (1991), “Origins of DSM-I. A Study in Appearance and Reality,” The American Journal of Psychiatry. 421–31.5. Wilson M.

Compton and Samuel B. Guze (1995), “The Neo-Kraepelinian Revolution in Psychiatric Diagnosis,” European Archives of Psychiatry and Clinical Neuroscience 245, no. 4. 198–9.6. Gerald L.

Klerman (1984), “A Debate on DSM-III. The Advantages of DSM-III,” The American Journal of Psychiatry. 539–42.7. Thomas E. Schacht (1985), “DSM-III and the Politics of Truth,” American Psychologist.

513–5.8. Daniel F. Hartner and Kari L. Theurer (2018), “Psychiatry Should Not Seek Mechanisms of Disorder,” Journal of Theoretical and Philosophical Psychology 38, no. 4.

189–204.9. Sami Timimi (2014), “No More Psychiatric Labels. Why Formal Psychiatric Diagnostic Systems Should Be Abolished,” Journal of Clinical and Health Psychology 14, no. 3. 208–15.10.

Allen Frances et al. (1994), “DSM-IV Meets Philosophy,” The Journal of Medicine and Philosophy. A Forum for Bioethics and Philosophy of Medicine 19, no. 3. 207–18.11.

Andrea Jobst et al. (2016), “European Psychiatric Association Guidance on Psychotherapy in Chronic Depression Across Europe,” European Psychiatry 33. 20.12. National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management.

Draft for Consultation, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/full-guideline-updated, 507.13. Ibid., 351–62.14. Ibid., 597.15. Note that in order to refer to specific trials reviewed in the guideline, rather than the full citation, the Study IDs from column A in appendix J5 have been used. See www.nice.org.uk/guidance/gid-cgwave0725/documents/addendum-appendix-9 for details and full references.16.

National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management. Second Consultation on Draft Guideline – Stakeholder Comments Table, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/consultation-comments-and-responses-2, 420–1.17. National Institute for Health and Care Excellence (2018), Depression in Adults, appendix J5.18. Peter Fonagy et al.

(2015), “Pragmatic Randomized Controlled Trial of Long-Term Psychoanalytic Psychotherapy for Treatment-Resistant Depression. The Tavistock Adult Depression Study (TADS),” World Psychiatry 14, no. 3. 312–21.19. American Psychological Association (2018), Clinical Practice Guideline for the Treatment of Depression in Children, Adolescents, and Young, Middle-aged, and Older Adults.

Draft.20. Jacqui Thornton (2018), “Depression in Adults. Campaigners and Doctors Demand Full Revision of NICE Guidance,” BMJ 361. K2681..

We live in try this web-site unprecedented times kamagra for sale. But what makes them without parallel is not the current kamagra crisis nor the continued problems facing minorities in our institutions. Rather, it’s that for the first kamagra for sale time, the problems of accessibility, rights and freedoms are now invading privileged spaces.

There can be no ‘getting back to normal’, because ‘normal’ only ever benefited the white, Western, patriarchal, abled and cis ideals. For many, the world is not suddenly on fire. €¦IntroductionMinecraft is a kamagra for sale computer game with no specific goals to accomplish.

The gameworld consists of three-dimensional (3D) cubes and objects which the player (Steve) can mine and build into infinitely complex (and logically impossible) structures. Steve sometimes encounters other characters kamagra for sale (‘mobs’), such as animals and hostile creatures. He can ‘spawn’ and destroy them.

While it looks like a harmless game of logical construction, it conveys some worryingly delusive ideas about the real world. The difference between real and imagined structures is at the kamagra for sale heart of the age-old debate around categorising mental disorders.Classification in mental health has had various forms throughout history. Mack and colleagues set out a history of psychiatric classification beginning in 2600 BC with Egyptian references to melancholia and hysteria.

Through the Ancient Greeks with Hippocrates’ phrenitis, mania, melancholia, epilepsy, hysteria and Scythian disease kamagra for sale. Through the Renaissance period. Through to 19th-century psychiatry featuring Pinel (known as the first psychiatrist), Kraepelin (known for observational classification) and Freud (known for classifying neurosis and psychosis).1Although the history of psychiatric classification identifies some common trends such as the labels ‘melancholia’ and ‘hysteria’ which have survived millennia, the label ‘depression’ is relatively new.

The earliest usage noted by Snaith is from kamagra for sale 1899. €˜in simple pathological depression…the patient exhibits a growing indifference to his former pursuits…’.2 Snaith noted that early 20th-century psychiatrists like Adolf Meyer hoped that ‘depression’ would come to encompass a broad category under which descriptions of subtypes would emerge. This did not happen until kamagra for sale the middle of the 20th century.

With the publication of the sixth International Classification of Diseases (ICD) in 1948 and the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 and their subsequent revisions, the latter half of the 20th century has seen depression subtype labels proliferate. In their study of the social determinants of diagnostic labels in depression, McPherson and Armstrong illustrate how the codification of depression subtypes in the latter half of the 20th century has been shaped by the evolving context of psychiatry, including power struggles within the profession, a move to community care and the development of psychopharmacology.3During this period, McPherson and Armstrong describe how subsequent versions of the DSM served as battlegrounds for professional disputes and philosophical quarrels around categorisation of mental disorders. DSM I and DSM II have been described as products of an American Psychiatric Association dominated by psychoanalytic psychiatrists.4 DSM III and DSM III-R have kamagra for sale been described as a radical rejection of psychoanalytic thinking, a ‘neo-Kraepelinian revolution’, a reference to the observational descriptive techniques of 19th-century psychiatrist Emil Kraepelin who classified mental disorders into two broad categories.

€˜dementia praecox’ and ‘manic-depression’.5 DSM III was seen by some as a turning point in the use of the medical model of mental illness, through provision of specific inclusion and exclusion criteria, and use of field trials and a multiaxial system.6 These latter technocratic additions to psychiatric labelling served to engender a much closer alignment between psychiatry, science and medicine.The codification of mental disorders in manuals has been described by Thomas Schacht as intrinsic to the relationship between science and politics and the way in which psychiatrists gain significant social power by aligning themselves to science.7 His argument drew on Szasz, who saw the mental health establishment as a therapeutic state. Zimbardo, who described psychiatric care as a kamagra for sale controlling force. And Foucault, who described the categorisation of the mentally ill as a force for isolating ‘the other’.

Diagnostic critique has been further developed through a cultural relativist lens in that what Western psychiatrists classify as a depression is constructed differently in other cultures.8 Considering these limitations, some critics have gone so far as to argue that psychiatric diagnostic systems should be abolished.9Yet architects of DSM manuals have worked hard to ensure the technology of classification is regarded as genuine scientific activity with sound roots in philosophy of science. In their philosophical defence of DSM IV, Allen Frances and colleagues address their critics under the headings ‘nominalism vs realism’, ‘empiricism vs rationalism’ kamagra for sale and ‘categorical vs dimensional’.10 The implication is that there are opposing stances in which a choice must be made or a middle ground forged by those reasonable enough to recognise the need for pragmatism in the service of clinical utility. The nominalism–realism debate is illustrated using as metaphor three different stances a cricket umpire might take on calling strikes and balls.

The discussion sets out two kamagra for sale of these as extreme views. €˜at one extreme…those who take a reductionistically realistic view of the world’ versus ‘the solipsistic nominalists…might content that nothing exists’. Szasz, who is characterised as holding particularly extreme views, is named as an archetypal solipsist.

There is implied to be a degree of arrogance associated with this view in the illustrative example in which the umpire states ‘there are no kamagra for sale balls and there are no strikes until I call them’. Frances therefore sets up a means of grouping two kinds of people as philosophical extremists who can be dismissed, while avoiding addressing the philosophical problems they pose.Frances provides little if any justification for the middle ground stance, ‘There are balls and there are strikes and I call them as I see them’, other than to focus on its clinical utility and the lack of clinical utility in the alternatives ‘naïve realism’ and ‘heuristically barren solipsism’. The natural conclusion the reader is invited to reach is that a middle ground of a heuristic concept is naturally right because it is not extreme and is naturally useful clinically, without specifying in what way this stance is coherent, resolves kamagra for sale the two alternatives, and in what way a heuristic construct that is not ‘real’ can be subject to scientific testing.Similarly, in discussing the ‘categorical vs dimensional’, Frances promotes the ‘prototype approach’.

Those holding opposing views are labelled as ‘dualists’ or ‘dichotomisers’. The prototypical approach is again put forward as a clinically useful middle ground. Illustrations are drawn from natural science kamagra for sale.

€˜a triangle and a square are never the same’, inciting the reader to consider science as value-free. The prototypical approach kamagra for sale emerges as a natural solution, yet the authors do not address how a diagnostic prototype resolves the issues posed by the two alternatives, nor how a prototype can be subjected to natural science methods.The argument presented here is not a defence of solipsism or dualism. Rather it aims to illustrate that if for pragmatic purposes clinicians and policymakers choose to gloss over the philosophical flaws in classification practices, it is then risky to move beyond the heuristic and apply natural science methods to these constructs adding multiple layers of technocratic subclassification.

Doing so is more like playing Minecraft than cricket. The National Institute for Health and Care Excellence (NICE) guideline for depression is taken as an example of the philosophical errors that can follow kamagra for sale from playing Minecraft with unsound heuristic devices, specifically subcategories of persistent forms of depression. As well as serving a clinical purpose, diagnosis in medicine is a way of allocating resources for insurance companies and constructing clinical guidelines, which in turn determine rationing within the National Health Service.

The consequences for recipients of healthcare are kamagra for sale therefore significant. Clinical utility is arguably not being served at all and patients are left at risk of poor-quality care.Heterogeneity of persistent depressionAndrea Jobst and colleagues note that ‘because of their chronic clinical course, approximately 40% of CD [chronic depression] patients also fulfil criteria for TRD [treatment resistant depression]…usually defined by the number of non-successful biological treatments’.11 This position is reflected in the DSM VAmerican Psychiatric Association (2013), the European Psychiatric Association (EPA) guidance and the ICD-11(World Health Organisation, 2018), which all use a ‘persistent’ depression category, acknowledging a loosely defined mixed group of long-term, difficult-to-treat depressive conditions, often associated with dysthymia and comorbid common mental disorders, various personality traits and psychosocial disability.In contrast, the NICE 2018 draft guideline separates treatments into those for ‘new episodes’ of depression. €˜further-line’ treatment of depression (equivalent to TRD), CD and ‘depression with co-morbidities’.

The latter is subdivided into treatments for kamagra for sale ‘complex depression’ and ‘psychotic depression’. These categories and subcategories introduce an unfortunate sense of certainty as though these labels represent real things. An analysis follows of how these definitions play out in terms of grouping of randomised controlled trials in the NICE evidence review kamagra for sale.

Specifically, the analysis reveals the overlap between populations in trials which have been separated into discrete categories, revealing significant limitations to the utility of the category labels.The NICE definition of CD requires trial samples to meet the criteria for major depressive disorder (MDD) for 2 years. Dysthymia and double depression (MDD superimposed on dysthymia) were included. If 75% of the trial population kamagra for sale met these criteria, the trial was reviewed in the CD category.12 The definition of TRD (or ‘further-line treatments’) required that the trial sample had demonstrated a ‘limited response to previous treatment’ and randomised to the further-line treatment at this point.

If 80% of the trial participants met these criteria, it was reviewed in the TRD category.13 Complex depression was defined as ‘depression co-existing with personality disorder’. To be classed as complex, 51% of trial participants had to have personality disorder (PD).14It is immediately clear from these definitions that there is a potential problem with attempting to categorise trial populations into just kamagra for sale one of these categories. These populations are likely to overlap, whether or not a trial protocol sets out to explicitly record all of this information.

The analysis below will illustrate this using examples from within the NICE review.Cataloguing complexity in trial populationsWithin the category of further-line treatments (TRD), 64 trials were reviewed. Comparisons within these trials were further subcategorised into ‘dose escalation strategies’, ‘augmentation strategies’ and ‘switching kamagra for sale strategies’. In drilling down by way of illustration, this analysis considers the 51 trials in the augmentation strategy evidence review.

Of these, two were classified by the reviewers as also fulfilling the criteria for CD but were not analysed in the CD category (Study IDs. Fonagy 2015 and Kocsis 200915) kamagra for sale. About half of the trials (23/51) did not report the mean duration of episode, meaning that it is not possible to know what percentage of participants also met the criteria for CD.

Of trials that did report episode duration, 17 reported a mean duration longer than 24 kamagra for sale months. While the standard deviations varied in size or were unreported, the mean indicates a good likelihood that a significant proportion of the participants across these 51 trials met the criteria for CD.Details of baseline employment, trauma history, suicidality, physical comorbidity, axis I comorbidity and PD (all clinical indicators of complexity, severity and chronicity) were not collated by NICE. For the present analysis, all 51 publications were examined and data compiled concerning clinical complexity in the trial populations.

Only 14 kamagra for sale of 51 trials report employment data. Of those that do, unemployment ranges from 12% to 56% across trial samples. None of the kamagra for sale trials report trauma history.

About half of the trials (26/51) excluded people who were considered a suicide risk. The others did not.A large proportion of trials (30/51) did not provide any data on axis 1 comorbidity. Of these, 18 did not exclude kamagra for sale any diagnoses, while 12 excluded some (but not all) disorders.

The most common diagnoses excluded were psychotic disorders, substance or alcohol abuse, and bipolar disorder (excluded in 26, 25 and 23 trials, respectively). Only 7 of 51 trials clearly stated that all axis 1 diagnoses kamagra for sale were excluded. This leaves only 13 studies providing any data about comorbidity.

Of these, 9 gave partial data on one or two conditions, while 4 reported either the mean number of disorders (range 1.96–2.9) or the percentage of participants (range 68.1–96.7) with any comorbid diagnosis (Nierenberg 2003a, Nierenberg 2006, Watkins 2011a, Town 201715).The majority of trials (46/51) did not report the prevalence of PD. Many stated PD as an exclusion criterion but without defining kamagra for sale a threshold for exclusion. For example, PD could be excluded if it ‘impacted’ the depression, if it was ‘significant’, ‘severe’ or ‘persistent’.

Some excluded certain kamagra for sale PDs (such as antisocial or borderline) and not others but without reporting the prevalence of those not excluded. In the five trials where prevalence was clear, prevalence ranged from 0% (Ravindran 2008a15), where all PDs were excluded, to 87.5% of the sample (Town 201715). Two studies reported the mean number of PDs.

2.0 (Nierenberg 2003a) and 0.85 (Watkins 2011a15).The kamagra for sale majority of trials (43/51) did not report the prevalence of physical illness. Many stated illness as an exclusion criterion, but the definitions and thresholds were vague and could be interpreted in different ways. For example, illness could be excluded if it was ‘unstable’, ‘serious’, ‘significant’, ‘relevant’, or would ‘contraindicate’ or kamagra for sale ‘impact’ the medication.

Of the eight trials reporting information about physical health, there was a wide variation. Four reported prevalence varying from 7.6% having a disability (Eisendrath 201615) to 90.9% having an illness or disability (Town 201715). Four used scales kamagra for sale of physical health.

Two indicating mild problems (Nierenberg 2006, Lavretsky 201115) and two indicating moderately high levels of illness (Thase 2007, Fang 201015).The NICE review also divided trial populations into a dichotomy of ‘more severe’ and ‘less severe’ on the grounds that this would be a clinically useful classification for general practitioners. NICE applied a bespoke methodology for creating this dichotomy, abandoning validated measure thresholds in order first to generate two ‘homogeneous’ groups to ‘facilitate analysis’, and second to create an algorithm to ‘read across’ different measures (such as the Beck Depression Inventory, the Hamilton Rating Scale for Depression (HRSD) and the Montgomery-Asberg Depression Rating Scale).16 Examining trials kamagra for sale which use more than one of these measures reveals problems in the algorithm. Of the 51 trials, there are 6 instances in which the study population falls into NICE’s more severe category according to one measure and into the less severe category according to another.

In four of these trials, NICE chose the less severe category (Souza 2016, Watkins 2011a, Fonagy 2015, Town 201715). The other two trials were kamagra for sale designated more severe (Barbee 2011, Dunner 200715). Only 17 of 51 trials reported two or more depression scale measures, leaving much unknown about whether other study populations could count as both more severe and less severe.Absence of knowledge or knowledge of absence?.

A key philosophical error in science is to confuse an absence of kamagra for sale knowledge with knowledge of absence. It is likely that some of the study populations deemed lacking in complexity or severity could actually have high degrees of complexity and/or severity. Data to demonstrate this may either fall foul of a guideline committee decision to prioritise certain information over other conflicting information (as in the severity algorithm).

The information may be non-existent kamagra for sale as it was not collected. It may be somewhere in the publication pipeline. Or it may be sitting in a database kamagra for sale with a research team that has run out of funds for supplementary analyses.

Wherever those data are or are not, their absence from published articles does not define the phenomenology of depression for the patients who took part. As a case in point, data from the Fonagy 2015 trial presented at conferences but not published reveal that PD prevalence data would place the trial well within the NICE complex depression category, and that the sample had high levels of past trauma and physical condition comorbidity. The trial also meets the guideline criteria for CD according to the guideline’s own appendices.17 Reported axis 1 comorbidity was high (75.2% had anxiety disorder, 18.6% had substance abuse disorder, 13.2% had eating disorder).18 The mean depression scores at baseline were 36.5 on the Beck Depression Inventory and 20.1 on the HRSD (severe and very severe, respectively, according to published kamagra for sale cut-off scores).

NICE categorised this population as less severe TRD, not CD and not complex.Notes1. Avram H kamagra for sale. Mack et al.

(1994), “A Brief History of Psychiatric Classification. From the kamagra for sale Ancients to DSM-IV,” Psychiatric Clinics 17, no. 3.

Snaith (1987), “The Concepts of Mild Depression,” British Journal of Psychiatry 150, no. 3. 387.3.

Susan McPherson and David Armstrong (2006), “Social Determinants of Diagnostic Labels in Depression,” Social Science &. Medicine 62, no. 1.

52–7.4. Gerald N. Grob (1991), “Origins of DSM-I.

A Study in Appearance and Reality,” The American Journal of Psychiatry. 421–31.5. Wilson M.

Compton and Samuel B. Guze (1995), “The Neo-Kraepelinian Revolution in Psychiatric Diagnosis,” European Archives of Psychiatry and Clinical Neuroscience 245, no. 4.

198–9.6. Gerald L. Klerman (1984), “A Debate on DSM-III.

The Advantages of DSM-III,” The American Journal of Psychiatry. 539–42.7. Thomas E.

Schacht (1985), “DSM-III and the Politics of Truth,” American Psychologist. 513–5.8. Daniel F.

Hartner and Kari L. Theurer (2018), “Psychiatry Should Not Seek Mechanisms of Disorder,” Journal of Theoretical and Philosophical Psychology 38, no. 4.

189–204.9. Sami Timimi (2014), “No More Psychiatric Labels. Why Formal Psychiatric Diagnostic Systems Should Be Abolished,” Journal of Clinical and Health Psychology 14, no.

(1994), “DSM-IV Meets Philosophy,” The Journal of Medicine and Philosophy. A Forum for Bioethics and Philosophy of Medicine 19, no. 3.

207–18.11. Andrea Jobst et al. (2016), “European Psychiatric Association Guidance on Psychotherapy in Chronic Depression Across Europe,” European Psychiatry 33.

20.12. National Institute for Health and Care Excellence (2018), Depression in Adults. Treatment and Management.

Draft for Consultation, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/full-guideline-updated, 507.13. Ibid., 351–62.14. Ibid., 597.15.

Note that in order to refer to specific trials reviewed in the guideline, rather than the full citation, the Study IDs from column A in appendix J5 have been used. See www.nice.org.uk/guidance/gid-cgwave0725/documents/addendum-appendix-9 for details and full references.16. National Institute for Health and Care Excellence (2018), Depression in Adults.

Treatment and Management. Second Consultation on Draft Guideline – Stakeholder Comments Table, https://www.nice.org.uk/guidance/gid-cgwave0725/documents/consultation-comments-and-responses-2, 420–1.17. National Institute for Health and Care Excellence (2018), Depression in Adults, appendix J5.18.

Peter Fonagy et al. (2015), “Pragmatic Randomized Controlled Trial of Long-Term Psychoanalytic Psychotherapy for Treatment-Resistant Depression. The Tavistock Adult Depression Study (TADS),” World Psychiatry 14, no.

3. 312–21.19. American Psychological Association (2018), Clinical Practice Guideline for the Treatment of Depression in Children, Adolescents, and Young, Middle-aged, and Older Adults.

Draft.20. Jacqui Thornton (2018), “Depression in Adults. Campaigners and Doctors Demand Full Revision of NICE Guidance,” BMJ 361.

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