In human communication, the spoken and unspoken words belong to both the sender and receiver Essay

Communication is the process of sharing meaning with others. The sender is the person who sends the massage and the receiver is the person who receives the massage. There are encoding and decoding processes that happen during this stage. The sender encodes his idea or thought into a massage. For instance, there is a policeman staring at you, and you somehow notice the action and panic. The exchange between sender and receiver occurs. As the receiver, when you notice his action, you will decode the body language and his serious facial expression and you will think that as a sign that you’re in trouble. This interpretation may due to your knowledge and experiences. These both encoding and decoding is very important. This kind of massage can be either in the form of verbal communication or non-verbal communication. Verbal communication or also known as spoken word can be divided into two types, oral verbal communication and non-oral verbal communication. Oral verbal communication is the usage moment when we utter the words or speaking whereas non oral verbal communication is the usage of alphabets system in a proper manner or in a simple word, writing form. Non-verbal communication or also known as unspoken word can also be divided into oral non-verbal communication and non-oral non-verbal communication. Non-verbal communication as a whole can be defined as’ those bodily actions and vocal quality that typically accompany a verbal massage and are usually interpreted as intentional’. A person who is standing on the basis to deliver a speech even though looks like he is only performing a verbal communication may also unintentionally performs non-verbal communication too. This can be seen through his body language for instances, body gestures, facial expressions and even eye contacts. This explains the theory given by Verderber that non-verbal communication and verbal communication can be both happen at the same time. In communicating with each other, language is one of the compulsory features that are required. According to Rudolph F. Verderber, language is the body of works and system for their use in communicating that are common to people of the same community or nation, the same geographical area, or the same cultural tradition. If the spoken language used by the sender is not as same as the receiver, it will lead to the problem in conveying the massage. Body language as opposite is universal and can be understood by almost everyone around the globe despite of their nationality, races, genders or even their mother’s tongue. Smile for an instance, sending the message that the doer is happy, friendly and also in a good mood. Shannon and Weaver are the creators of the first communication model. This model was first created to show how the radio and telephone is working. There are three major parts of this model which ate sender, channel and receiver. The sender will encodes and transmitted the messages in form of binary code or data through the channel. The receiver then will receive and decodes the data into understanding messages. Plus, during the process of sending the messages, there may be some interruption or noise happened either internally or externally. This may due to the imbalance hormone, lack of information, crowd noise or even health problem. Communication begins with self. This principle explains how one’s experiences and knowledge affects his or her ways in treating and communicating other people. Experts also agree that people are products of how others treat them and of the messages others send them. I quoted Carl Rogers, â€Å"every individual exists in a continually changing world of experience of which he is the center.† Someone who experienced either bad or good experiences in his past will have already prepared if the same situation occur again. For example Ali was once been scolded by his lecturer when he did nit hands in the assignment during the due date, this will become a turning point or lesson for him so that in the future he won’t repeat the same mistake again. Communication at the same time is also complicated. The combination of verbal, non-verbal, behavior and attitude of speakers, the intonation and other factors when they combine will make the messages hard to be understood. Moreover, the usage of high-level vocabularies, the complicated structures and uncommon term will make even the simplest message hard to comprehend. As conclusion, in ensuring the communication between two parties is successful, they must have the most important aspect of communication, which are mutual respect and mutual understanding.

Benjamin Franklin Essay

Can a man be as vast as a nation? Did the life-experiences and cultural contributions of a single individual play as pivotal a role in the establishment of American democracy and American culture as any written declaration, constitution, or law? Without a doubt, there are historians who stand at the ready to assert that Benjamin Franklin was just such an individual. Numerous books, scholarly articles, essays, encyclopedias, and even works of fiction have contributed and continue to contribute to the mythic status of Benjamin Franklin in American history. However, there is is good reason to reject any surface-level interpretation of Franklin’s important contributions to the founding of American Democracy, and read with great care the complex and extensive evolution of Franklin’s actions and stated philosophies over the span of a great many years. The resulting image of Franklin when the myth of Franklin and the historical Franklin are compared is one of a challengingly deep and complex thinker, and of a man who acted in keeping with his deepest philosophical, moral, and spiritual beliefs — many of which were quite radical in his day and many of which were astonishingly traditional. The truth of the matter is that â€Å"†Franklin’s extant writings are so rich and voluminous that one can find almost any sort of Franklin one wishes to find,† (Frasca, 2007) but, certainly, in comparing the historical Franklin to the mythic Franklin, important insight into American history and into the psychology of American culture can be gained. Franklin’s career can be said to have begun very early in his life, when he â€Å"left school at 10 years of age to help his father† (â€Å"Franklin, Benjamin,† 2007); not long afterward, he â€Å"was apprenticed to his half brother James, a printer and publisher of the New England Courant, to which young Ben secretly contributed. After much disagreement he left his brother’s employment and went (1723) to Philadelphia to work as a printer† (â€Å"Franklin, Benjamin,† 2007). Franklin’s early life was later given its first â€Å"boost† toward mythic status with posthumous publication of Franklin’s â€Å"Autobiography† in 1791, not long after Franklin’s death. If the â€Å"Autobiography† helped to foster the mythic status of Franklin in American history, it was but one of the many examples of Franklin’s written contributions to American culture. During his active career, Franklin was immersed not only in science and history, but in philosophy and ethical theory as well. His popular writings contained both humor and moral axioms — notably in his very popular publication, â€Å"Poor Richard’s Almanac,† which was â€Å"In his day the great source of profit to every printer [†¦ ] which was issued yearly, and which was the vade-mecum in every household that could spare the necessary two or three pence annually† (Ford, 1899, p. 400). Franklin’s steady contributions to American popular culture during his lifetime included not only the folk wisdom of Poor Richard, but with much-needed humor for the American continent: In America, however, either because the immigrants had been recruited from the unfortunate and the religiously austere, or because the hardness of the conditions resulted in a sadness which tinctured the lives of the people, there seems to have been a practical extinction of all sense of the humorous. (Ford, 1899, p. 388) Against this background, Franklin — himself often a deep-thinker and a moody person — articulated the first instances of a natively American sense of humor. This fact is very important in evaluating both the mythical and the historical Franklin because the mythic Franklin remains empty of all but a few slight traces of Franklin’s triumphant career and reputation as a humorist. His status as such is very important because, as mentioned, it is Franklin’s cultural contribution to America as well as his political contributions which cements his status as a Founding Father and which has resulted in the extensive influence Franklin has held over American culture from its earliest beginnings. Franklin used humor in a very conscious way to pave the way for his more considered ethical and moral ideas; more importantly he seized the opportunity to define humor in America for generations: â€Å"perhaps his most remarkable attribute is that the future historian of the now famous American humor must begin its history with the first publication of Poor Richard† (Ford, 1899, p. 389) and, by doing so, Franklin placed himself in a key position to define through humor just what it mean to be an American. His capacities as a humorist do not seem to have been affected, but rather emerged naturally out of his personality. Franklin used humor to not only define himself and to partially define American culture, but as a method to settle scores or take shots at traditional beliefs or institutions: â€Å"His irresistible inclination to screw a joke out of everything is illustrated by the scrapes he got himself into with his advertisers. Employed to print an announcement of the sailing of a ship, he added an â€Å"N. B. † of his own, to the effect that among the passengers â€Å"No Sea Hens, nor Black Gowns will be admitted on any terms. † Some of the clergy, properly incensed, withdrew their subscriptions from the â€Å"Gazette. † Yet this did not cure him of the tendency, and he was quickly offending again. (Ford, 1899, p. 394) Humor and literary works provided one means for Franklin to influence the development of early American culture and these aspects are slightly contained in the myth of Benjamin Franklin, with the humorous aspects downplayed. For example, â€Å"Poor Richard’s Almanac† is probably part of the Franklin myth in most people’s minds and they probably also are aware that Franklin offered axioms of wisdom in this Almanac, but many people are probably deeply unaware that Franklin’s gift for humor was not only an important part of his literary output, but an aspect of his personal philosophy and a method by which he engaged other people and also helped to resolved conflicts. Another aspect of the Franklin myth is that he â€Å"invented† electricity by tying a key to a kite-string. Like many myths, this myth has a basis in historical reality: â€Å"His experiment of flying a kite in a thunderstorm, which showed that lightning is an electrical discharge[†¦ ] and his invention of the lightning rod[†¦ ] won him recognition from the leading scientists in England† (â€Å"Franklin, Benjamin,† 2007) but it is a slim basis. What the â€Å"lightning and key† myth represents in a compressed form is the long and complex contribution to the natural sciences and to popular inventions which actually was a part of the historical Franklin’s career. In regards to his actual scientific achievements, Franklin is noted by historians to have been a brilliant inventor and adapter of existing technologies: â€Å"He repeated the experiments of other scientists and showed his usual practical bent by inventing such diverse things as the Franklin stove, bifocal eyeglasses, and a glass harmonica† (â€Å"Franklin, Benjamin,† 2007); he is regarded as having a very brilliant scientific mind and a keen sense of practical implementation of abstract ideas. These qualities are also present in Franklin’s philosophical and political ideas which will be discussed shortly and together, Franklin’s scientific, philosophical. and political vision actually coincide with the â€Å"popular† aesthetic already shown to have been a part of his literary output. In some ways, Franklin’s cultural contributions mirror a deeply democratic sense of purpose and fulfillment: the creation of common axioms, a common wisdom, along with useful technologies are not separate from Franklin’s political vision. Ironically, the egalitarianism which is inferred in Franklin’s guiding principles is less present on the surface in his specifically political writings. When specifically considering Franklin’s political beliefs and writings, it should be pointed out that Franklin was actually â€Å"very different from the other Founding Fathers. He was older and more committed to the British Empire and certainly more cosmopolitan and urbane than they were† (Morgan, 2005, p. 551) and because Franklin lived abroad for just under twenty years in England and having traveled a lot through Europe, Franklin was in many ways â€Å"the least American of the revolutionaries† (Morgan, 2005, p. 551). This duality in the historical Franklin is, of course, completely absent from the â€Å"lightning and key† mythic Franklin who is regarded as a Founding Father of American democracy. This last idea of the myth of Franklin is true enough, but as this paper has hopefully shown, the historical picture of Franklin is a more ambiguous and much more complex than the myth. This is an understandable condition because part of what myth does with historical events is to simplify them and streamline them so that the symbolic impact can be made more powerful and less diluted by alternate interpretation. It would be difficult if not impossible, for example, to generate a mythic vision of Franklin which included the historical reality that Franklin â€Å"preferred the social and intellectual life of London to that of Philadelphia† (Morgan, 2005, p. 551) or that â€Å"his landlady, Margaret Stevenson, and her precocious daughter, Polly, provided Franklin with more compatible intellectual companionship than did his own wife and daughter† (Morgan, 2005, p. 551) so these very real and very important aspects of Franklin’s actual life and his actual personality are absent from the Franklin myth. Yet these aspects, and others, are extremely important in helping to define and understand what exactly Franklin contributed as a Founding Father of American democracy. That his cultural contributions, whether humorous, literary, or scientific not only fostered his myth but actually altered the course and evolution of American society is demonstrable by way of historical evidence. What, then, were Franklin’s political contributions to the early American nation? Did Franklin evidence as much resourcefulness and thoroughness in his political career as he evidenced in his career as a printer, or humorist, or inventor? One very interesting aspect of Franklin’s life is that he dealt with not only the revolt of the American colonies against a British Empire which he loved, but also with the resulting estrangement from his own (illegitimate) son during the course of the war. Franklin’s actions at the outbreak of the Revolutionary War give a solid glimpse into his sympathies and beliefs at the time: As trouble between the British government and the colonies grew with the approach of the American Revolution, Franklin’s deep love for his native land and his devotion to individual freedom brought (1775) him back to America. There, while his illegitimate son, William Franklin, was becoming a leader of the Loyalists, Benjamin Franklin became one of the greatest statesmen of the American Revolution and of the newborn nation. (â€Å"Franklin, Benjamin,† 2007) As a statesman, Franklin’s contributions can be at least to some degree quantified and cited: he was postmaster general, a delegate to the Continental Congress, an appointee and signatory to the committee which wrote the Declaration of Independence, he was also â€Å"sent to Canada with Samuel Chase and Charles Carroll of Carrollton to persuade the people of Canada to join the patriot cause† (â€Å"Franklin, Benjamin,† 2007). The mythic vision of Franklin as a powerful statesman delivering powerful, moving oratory before the Continental Congress, or laboriously poring over draft versions of the Declaration of Independence are confronted by anecdotes of historical fact. An example of this is John Adams, who â€Å"contemptuously described a Franklin â€Å"from day to day sitting in silence, a great part of the time fast asleep in his chair† and sighed that he was likely nevertheless to get credit for everything achieved by the Congress,† (Lopez & Herbert, 1975, p. 203). Again, Franklin’s political reputation was based not so much in his perception among his American colleagues, but in his foreign popularity and fame. His best tactic was not spell-binding oratory or intricate legalese, but in injecting â€Å"a calm pronouncement or a bit of humor† (Lopez & Herbert, 1975, p. 203) into difficult political processes. The question still remains as to what Franklin, personally, believed about the American Revolution — during the time of the revolt and afterward — and whether or not Franklin can be accurately described as a firm believer in democratic principles. The historical facts suggest that Franklin held conflicting views about democracy and royalist rule. On the one hand, he advocated personal liberty, on the other, he seemed reluctant to dismiss with the notion of a royalist government altogether. As he wrote in the â€Å"Autobiography,† his feelings were not at all certain during the time of the approaching revolution: â€Å"In our way thither I projected and drew up a plan for the union of all the colonies under one government, so far as might be necessary for defense, and other important general purposes† (Franklin, 1914, p. 131) but here there is no mention of a constitution or a strong Federal government at all. Franklin’s own visions for â€Å"a single-chamber congress and a weak executive council were rejected† (â€Å"Franklin, Benjamin,† 2007) and, alter, although he objected to aspects of the final Constitution, â€Å"he helped to direct the compromise [and] worked earnestly for its ratification’ (â€Å"Franklin, Benjamin,† 2007). The picture which emerges of Franklin as a politician is one of a man whose core-principles were challenged by the birth of a new government, but who fought resolutely on behalf of the new nation without regard for the degree to which it mirrored, exactly, his always-evolving personal beliefs. In addition to the differences which are evident between Franklin the myth and Franklin the historical figure in regard to his literary, scientific, and political contributions to American history, two other areas of Franklin’s life are absent from the mythological figure of Franklin: his religious and racial convictions. Of course, it is absolutely true that Franklin’s religious convictions and his views on race and ethnicity evolved throughout his lifetime. On the other hand, Franklin’s religious beliefs seemed to occupy a central place in his interpretation of his own life’s purpose and the meaning of his life. Where religion is concerned, Franklin’s most intimate beliefs depict a rather traditional point of view. Because of his personal experiences and personal fortunes, Franklin tended to view the arc of his life in rather conventional religious terms: â€Å"Scattered through his writings are sentences full of gratitude to God for His favor in lifting him up from such a low to such a high estate, in bringing him substantially unscathed through the graver dangers and baser temptations of human life, and in affording him the assurance that the divine goodness, of which he had received such signal proofs in his career, would not cease with his death† (Bruce, 1917, p. 51) — these simple, but enduring, beliefs are easily compatible with many forms of American Christianity. That said, it would be very difficult to trace an influence from Franklin to modern Christianity, nor an influence of Christianity directly on the myth of Franklin. In both fact and in myth, Franklin’s traditional religious ideas are downplayed due, presumably, to their being conspicuously in keeping with the common ideas of Franklin’s time. Interestingly enough, Franklin retained his religious convictions at the close of his very eventful life and the fruition of his religious convictions strengthened him in old age and in death. As one of his biographers wrote: â€Å"WHEN THE DAY CAME, April 17, 1790, he was ready. All his life he had been gingerly taming death, stripping it of its awe and power, clothing it in appealing metaphors of travel and bliss, humoring it, giving it a place in the family circle† (Lopez & Herbert, 1975, p. 308) and because of his receptiveness to deeply held religious convictions which were, nonetheless, not tied to any kind of dogma or strict adherence to religious doctrine, Franklin’s religious philosophies and his actual death are gestures, also, of a democratic sprit and and individualist. The conflict which the religious side of the historical Franklin presents for the mythic vision of Franklin is difficult to articulate. It has to do with the fact that, while Franklin’s individualistic take on Christian principles and religious ideas does, in fact, make a very compatible fit with the American notion of individual liberty, Franklin’s avoidance of traditional dogma and doctrine results in making his individualistic religious beliefs more difficult to define and express to a popular audience. Just as there is no easy mythical expression for Franklin’s humor, as there is for his scientific prowess, there is no ready mythic symbol for his peculiarly individualistic religious beliefs which are rooted in traditional Christianity. Just as Franklin’s religious attitudes fail to find mythic expression, his ambiguous views on race and racial prejudice also are a poor fit for the Franklin myth. The attentive observer of history will take into consideration that at various points in his life, Franklin was demonstrably racist and xenophobic: â€Å"Franklin was clearly unhappy about the great number of Germans who were immigrating to his home town of Philadelphia, even though many supported him by patronizing his printing business† (Lapham & Saunders, 2005) and also, Franklin — prior to the Revolutionary War — â€Å"grumbled about Philadelphia’s bilingual (English and German) street signs and complained that the Pennsylvania parliament needed to use translators† (Lapham & Saunders, 2005). In addition to these historical facts, there is evidence that Franklin was not only racist, but perhaps a bit paranoid about other races and cultures. He wrote on one occasion, â€Å"That the Number of purely white People in the World is proportionably very small†¦. † (Lapham & Saunders, 2005) which in and of itself might be considered merely an observation of fact until it is paired with Franklin’s words, which preceded the statement: â€Å"Why should Pennsylvania, founded by the English, become a Colony of Aliens, who will shortly be so numerous as to Germanize us instead of our Anglifying them† (Lapham & Saunders, 2005). These kinds of historical details and indications of Franklin’s character have no place in the Franklin myth. Their impact on the historical influence of Franklin is one which is very complicated and fascinating because the evolution of Franklin’s thoughts and actions in regard to issues of race underwent a profound change throughout his life. Although Franklin seemed to regard one race being in conflict with another in some of his writings, he nevertheless, â€Å"was chosen to be president of one of the first anti-slavery societies in America,† (Lapham & Saunders, 2005) and he went on to help to â€Å"create black schools, assist free blacks to obtain work, promote family-friendly values, and improve the social conditions black children† (Lapham & Saunders, 2005). The most important aspect of Franklin’s views on racism is that his ideas â€Å"evolved over his lifetime, becoming more tolerant and egalitarian as he grew older† (Lapham & Saunders, 2005), however, even such a dramatic and ultimately positivistic aspect of Franklin’s historical biography is left out of the Franklin myth. A letter to Franklin from his sister seems to encapsulate the very kinds of ambiguities and vagaries which the myth of Franklin exists to erase. His sister remarks of the American revolution: â€Å"to Propagate Is stufed into them, & it is Dificult to know whither Either Party are in the Right. for my Part I wish we had Let alone strife before it was medled with & folowed things that make for Peace† (Van Doren, 1950, p. 107) and from this letter and others like it, the modern observer is able to glean at least a partial understanding that ideas and conflicts in Franklin’s time were no more clear, no more â€Å"black and white† than they are in our own. In conclusion, while the myth of Benjamin Franklin, the man who â€Å"discovered† electricity with a key tied to a kite, the man who â€Å"wrote† the Declaration of Independence, a man who is one of the Founding Fathers of America, is a powerful and enduring myth, the historical facts of Franklin’s long and eventful life offer and a more authentic illustration of early-American philosophy, politics, and culture. The conflict between the myth of Franklin and Franklin the historical figure is rooted in the fact that historical truths are often ambiguous, complex and difficult to express succinctly, whereas myth, while sacrificing authenticity often makes a far more expedient impact on popular consciousness. Franklin the historical figure achieved a far greater influence practically over the development of American culture and American politics than the myth is capable of expressing; however, the historical facts of Franklin’s life also sometimes stand in stark opposition to the myth which they, at least in part, began. References Bruce, W. C. (1917). Benjamin Franklin, Self-Revealed: A Biographical and Critical Study Based Mainly on His Own Writings (Vol. 1). New York: G. P. Putnam’s Sons. Franklin, Benjamin. (2007). In The Columbia Encyclopedia (6th ed. ). New York: Columbia University Press. Ford, P. L. (1899). The Many-Sided Franklin. New York: The Century Co. Franklin, B. (1914). The Autobiography of Benjamin Franklin. New York: Macmillan. Frasca, R. (2007). Benjamin Franklin Unmasked: On the Unity of His Moral, Religious, and Political Thought. The Historian, 69(2), 359+. Lapham, S. S. , & Saunders, A. (2005). Benjamin Franklin’s Evolving Views on Race and Ethnicity. Social Education, 69(1), 13+. Lopez, C. , & Herbert, E. W. (1975). The Private Franklin: The Man and His Family. New York: W. W. Norton. Morgan, D. T. (2005). The Americanization of Benjamin Franklin. The Historian, 67(3), 551. Van Doren, C. (Ed. ). (1950). The Letters of Benjamin Franklin & Jane Mecom. Princeton, NJ:

Beowulf Comparison Essay

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Cash - Case Study Example The growth in these sectors not only brings in additional income and revenue in the economy but also ensures that it remains stable. The decision by the Indian government to ease restriction on foreign ownership has attracted foreign players into the telecommunication, hospitality, aviation and transport industry. All these have led to economic growth thus making India a land of opportunities. The Indian government has continued to show a lot of interest in foreign investments. Policies intended to attract more investors have been passed. 2. The resources and capabilities of the international hotels are considered to be among the fundamental sources of competitive advantage within the areas they are operating in. Most of these international hotels have been in operation for quite a long time and they own several properties in various world locations. According to Enz (2010), international firms and hotels have resources that allow them to not only have an upper hand compared to local hotels but also attain superior performance. The advantage can be sustained over a long period of time to an extent that such hotels are able to protect themselves from resource imitation, substitution and even transfer. Armstrong (2011) points out that a company’s internal resources which include cash and other capabilities are more important than the external factors when it comes to achieving and sustaining competitive advantage. Resources like employee, experience and skills basically help in exploiting opportunities and also neutralizing potential threats. 3. India continues to grab headlines for its economic growth and boom. The high growth rates have not been ignored in the global discussion. International firms have therefore decided to open up their deep pockets as part of their investment strategies in the global markets. Despite the rising need for the services, the local firms and chains must come up with policies that will not only allow them

Relationships Between Nursing, Health, and the Policy Processes Article

Relationships Between Nursing, Health, and the Policy Processes - Article Example This is because several laws and policies within the country support abortion. The woman also indicated that her health was in danger because the pregnancy affected her psychological well-being because she conceived under duress. The policy that best typifies the case study is Access to Abortion Services that give women rights to abort. This right allows women to access abortion services, as well as support within health care units. The act also creates access routes, and prohibits derogatory actions such as harassments. Some of the access routes include the health care facilities, physicians’ offices, and other service providers (College of Registered Nurses of British Columbia, 2013). Additionally, individuals receiving abortion services and issuing financial and emotional support are protected. The legalization of abortion has been controversial in the United States for the past 200 years making it difficult for the process to enjoy the protection of the law (Simmonds, 2013). Currently, women in the United States have legal abortions right granted throughout the pregnancy period. Furthermore, the women have the right to abort in almost all situations especially after Supreme Court announced the inc orporation of abortion rights into the constitution. This implies that any lawful barriers that will hinder the females from having abortion are unconstitutional (Abort73.com, 2009). This policy involves the nursing process because the service providers include the nurses who offer the abortion services and care based on the provisions of the act. This means that it is illegal for nurses to refuse to give abortion services to females especially when the circumstances are justifiable. I supported the nurses’ decision in the case study. This is because the elements of the abortion policy contradict religious practices. According to my religion, abortion is sin because it constitutes murder.

Organized Crime and Kentucky Research Paper Example | Topics and Well Written Essays - 3000 words - 1

Organized Crime and Kentucky - Research Paper Example When considering organized in the United States, one often hears a discussion centering around the crime families of New York, Philadelphia, and Chicago.   In fact, much is known about the organized criminal elements throughout history in these major cities.   We can trace their development, origin, and arrive at various sociological theories to explain away their existence.   Less is understood, however, about the reality that organized crime has also flourished throughout the rural areas of America during the course its relatively young existence.   Kentucky is certainly a worthy example of this. We know, for example, those criminal elements are not only a part of the state's history, but that organized groups continued to develop in Kentucky throughout the 1940s and 50s.  Such organizations became a central part of society in the areas of Newport and Covington. Sociologists have long been interested in studying the perplexity that would create the need for such organized crime.   What has been discovered is that individuals will typically continue to seek out access to those activities that are either deemed illegal by the government or taboo by current the current standards and mores of society.   Examples of these, common during the Kentucky of the 40s and 50s, include illicit gambling activities, bootleg liquor, prostitution services, and a host of others. The history of Kentucky is certainly layering with various groups that have sought to capitalize on these areas of gambling and vice.

Fiat Failure Case Study Example | Topics and Well Written Essays - 2500 words

Fiat Failure - Case Study Example Finally this study has particularly identified Fiat's inability to reorganize its internal and external strategic value chain and supply chain management processes to achieve positive synergies related to costs and corresponding benefits. More than a century of operations at Fiat were essentially characterized by typical Italian family business approach. The Agnelli family dynasty has been controlling Fiat ever since its inception and even today the family and its related people have roughly 34% of the shares. The company was growing from strength to strength, diversifying in the process in to one of the biggest European Business Conglomerate (Cammarata, Kurucz, Maj, Pavlovic & Portmann, 2006). Its diversification strategy spread in to a number of unrelated businesses as well. Aircraft manufacturing to pharmaceuticals Fiat spread its organizational umbrella. Currently its mammoth organizational structure has become unwieldy. Fiat has been going through a series of downs and very rare ups for a number of years now (Barry, 2009). The organization's inability to come to terms with the changing patterns of international trade and above all its structural orientation in the rapidly changing external competitive environment was not only flawed but also strategically divergent. It is the latter problem that affected the company much more than any other. The recent efforts to turn around the company financially and operationally have been met with no success because in the first place the company has been relying too much on corporate outcomes related to volume sales and capturing market shares while its smaller rivals have been concentrating on technology related productivity goals to identify niche markets in far corners of the globe(Landmann, Wolters, Bernhart & Harsten, 2000).Despite a growing threat coming from these bigger competitors, Fiat was more or less occupied with fluid external environment that pa rticularly had an impact on new product launches rather than testing the mood of the customer. Fiat's inability to effect internal structural changes along with a focus on the rapidly transient strategic competitive environment has been the main reason for its current debacle. While its competitors concentrated on merger and acquisition (M&A) related synergies, there was very little or no effort by Fiat to integrate its existing scale related advantages in to the existing operational environment (Fiat News, 2009). Thus its strategic market orientation was lacking in many respects. 2. Research aim The research aim of this paper is to establish a series of correlations and regressions

Ethnic group Essay Example for Free

Ethnic group Essay Race in America is one of those subjects that scholars rarely broach and are heavily criticized for these omissions by their constituents. For this reason, the subject of race and urbanization felt a proper choice for this final paper. Following, we will incorporate data from multiple sources including Khaled Hosseini’s The Kite Runner, a novel that examines the harrowing trials of different groups in Afghanistan and what happens to the ones lucky enough to escape the violence of their homeland into the safety net of American soil; in an attempt to show the inalienable link between race and urbanization. This discussion on urbanization and race in American will also include a brief discussion on classism. Classism is a part of the structural organization of society that can be measured as part of the contributing factors to the socioeconomic divisiveness experienced in this urbanized world. Some argue that gentrification, in all of its wonders is class based. Others argue it more a matter of ethnicity and race, both may be correct. Nevertheless, the issue of race, as aforementioned should be granted a closer look. By examining the ideas and experiences of anthropologists and sociologists past and present this paper will attempt to specify on how classism, racism, and urbanization are connected. Growing Cities and Ghettos The Industrial Revolution sparked an enormous wave of migrants and immigrants into American cities creating an urban ecology. Chapter 3 of the Giddens et. al. text, describes the social movement from Gemeinschaft to Gesellschaft; from a community based ideology in society to a more individualized world. Afghanistan is an agriculturally based society. Urbanization is a global process that draws people away from rural areas and into the cities. Once in those cities, people tend to gravitate to areas that are inhabited by people of their same cultural fabric. In discussing theories of urbanization, gentrification and displacement, John Bentacur (2010) in Gentrification and Community Fabric in Chicago points out how people are drawn to areas that have a cultural/ethnic connectivity, â€Å"immigrants with different characteristics compete for space until they get accommodated with alike others in locations that correspond to their competitive strengths† (p 384). In the novel, The Kite Runner, Amir and his father make the arduous migration from Kabul, Afghanistan to Fremont, California. Their low income neighborhood of Fremont is ethnically diverse but with a notable concentration of Afghani residents. It makes sense that when people leave their countries of origin to settle in a new place, they will be drawn to people and areas that are familiar to them. Even with familiarity problems arise, urban studies reveal several difficulties that plague densely populated urban neighborhoods; poverty, crime and dilapidated conditions to name a few. In Afghanistan Baba, Amir’s father, was rich and even wielded some power for being a respected business man and serving the community by creating an orphanage that would later be destroyed by the Taliban regime. In America, there would be no such accolades to speak of for their family. In fact, they would live in a type of poverty, they had never experienced nor hardly imagined. They would experience the existence that many black Americans face with no end in sight. A growing world population combined with globalization and the heightened mobility that comes with it has led to the creation of cities and a scramble for affordable housing. Gentrification also known as ‘urban regeneration’ or ‘re-urbanization’ is the process that happens in a community when it becomes urbanized and consists of the higher income families moving into lower income areas. During this process demographic changes are notable; in America, gentrification is notably marked by white families moving into black neighborhoods. Race and Ethnicity America is a multicultural nation. Our history of slavery created the black and white groups and the immigrant populations from around the world contributes to a high variety of culture and ethnic background. The macro-sociological issue of race and ethnicity has been the source of much debate and discussion. The reason for this is that the issue of race has been the root cause of social and political turmoil. Douglas Massey and Nancy Denton provide the backdrop in history when segregation by race was created in America in their book American Apartheid: Segregation and the Making of the Underclass. Massey and Denton edify that racial segregation was not always a fact of life in American society and that in fact; blacks and whites lived in close proximity to each other, albeit in the alley ways of the big homes occupied by their white neighbors, â€Å"industrialization in the north unleashed a set of social, economic and technological changes that dramatically altered the urban environment in ways that promoted segregation between social groups† (1993:19-26). Urbanization and technological advancement (causing blacks in the south to migrate to northern cities by the tens of thousands) would be the foundation for residential segregation where blacks and other minorities would be relegated to the outskirts of town. Black ghettos would remain isolated from society in a manner that was rarely, experienced by the European immigrants that came to this country during industrialization. Blacks and later, Latinos, would be destined to live isolated and neglected from social organizations and deprived from many of the benefits enjoyed by white communities with little hope of escape, â€Å"not only was the segregation of European ethnic groups lower, it was also temporary. Whereas Europeans isolation indices began to drop shortly after 1920, the spatial isolation characteristics of blacks had become a permanent feature of the residential structure of large American cities by 1940† (Massey and Denton 1993:57). In America, race and ethnicity is more clearly defined than in places like Afghanistan. According to data gathered from the PBS News Hour website, Afghanistan has nine different ethnic groups that reside in different territories of the country. They have fought and continue to fight civil wars, over culture (religion), legislative power and territory. Afghanistan and the U. S. are similar in their historical oppression of one ethnic group over another. In Afghanistan, the Pashtun/Sunni have for a long time ruled the land and claimed dominion over the Hazara/Shites. The Hazara group can be considered the equivalent to the Black demographic in America where historically they were the slave class, but are currently represented in government. Statistics In a rapidly modernizing world, Afghanistan is among the severely underdeveloped countries of the Middle East. As previously mentioned, Afghanistan is a multiethnic/multifaith, agriculturally based democracy, with a history of violence. And it perhaps it is this history, in addition to deep religious belief systems that have kept this land from joining the rest of the modern world. In reviewing the Millennium Development Goals indicators, data collected by the United Nations Statistics Division (UNSD), I reviewed several indicators that point to the fact that Afghanistan has a long road ahead. Afghanistan is making slow but sure progress trying to bring itself into a socially, politically and economically stable place. The first indicator measured the number of underweight children less than 59 months. The UNSD defines this indicator as a high number of moderately to severely underweight children, â€Å"whose weights for age are less than two standard deviations†. According to the report a healthy population will have 2. 3 percent of their children in this category. In 2004, 32. 9 percent of Afghanistan’s children were reportedly underweight, compared to 44. 9 percent in 1997. This indicator points to the poverty level and lack of nourishment recorded within a seven year period in Afghanistan. A second indicator measures women’s rights and representation in government. This indicator is defined as, â€Å"the portion of seats held by women in national parliament† increased from 3. 7 percent in 1990 to 27. 3 percent in 2006. The measurement was sustained through 2012 at 27. 7 percent. More work needs to be done and educating the population should be the place to start. Theological Link The Modernization Theory discussed in the text looks to explain the underdevelopment of countries like Afghanistan. Marx worried about capitalism and the effects it had on the lower-class population and thereby, the democratic process. Marx’s Conflict Theory dictates that societies are ruled by a small group of elite that create social order for the larger population. In this, we have the creation of divisions by class (division of labor), a central topic of discourse since the beginning of industrialized times. The French Revolution of 1787 (also known as the revolt of the bourgeois or middle-class society) creating capitalism and thereby usurping government power from monarchs. Karl Marx hated democracy. â€Å"Democracy is the road to socialism† (Karl Marx) Capitalism created tensions between the working and bourgeois classes. Summary Race and urbanization are indivisibly linked. Marxism and Class Conflict is the most applicable theory of today’s society. Considering the current events and status of world order, it is undeniable; capitalism continues to be the most powerful ideology in the world. The United States is a powerful country and the way it retains power is by unwaveringly maintaining capitalistic ideology and participating in global conflict around the world in defense of this ideology, â€Å"power, ideology, and conflict are always closely connected† (Giddens 2012:20). Societies are based on trust and these trusts are broken by the people that create and uphold unjust rules for the population of color and the poor. Works Cited Betancur, John. 2010. â€Å"Gentrification and community fabric in Chicago. † Urban Studies Journal Foundation. Sage 48(2): 383 407. Retrieved from http://usj. sagepub. com/content/48/2/383 Giddens, Anthony, Mitchell Duneier, Richard P. Applebaum and Deborah Carr. 2012. â€Å"Introduction to sociology. † New York: W. W. Norton and Company. Eighth ed. , pp. 15-78. Massey, Douglas and Nancy A. Denton. 1993. â€Å"The construction of the ghetto. † Pp 17-59 in American Apartheid: Segregation and the Making for the Underclass. Harvard University Press. Retrieved from http://ereserve. baruch. cuny. edu. remote. baruch. cuny. edu/eres/coursepage. aspx? cid=3155page=docs United Nations Statistics Division. (1991-2011) [Table Data on Gender Parity Index in Primary Enrollment retrieved November 5, 2012. ] Millenium Development Goals Indicators. Retrieved from http://mdgs. un. org/unsd/mdg/Metadata. aspx? IndicatorId=0SeriesId=559 United Nations Statistics Division. (1991-2011) [Table Data on Gender Parity Index in Primary Enrollment retrieved November 5, 2012. ] Millenium Development Goals Indicators. Retrieved from http://mdgs. un. org/unsd/mdg/Metadata. aspx? IndicatorId=0SeriesId=557.

A Guide Into Business Intelligence Studies Information Technology Essay

A Guide Into Business Intelligence Studies Information Technology Essay Data Warehousing: Integration of data from multiple sources into large warehouses and support of on-line analytical processing and business decision making DW vs. Operational Databases Data Warehouse Subject Oriented Integrated Nonvolatile Time variant Ad hoc retrieval Operational Databases Application oriented Limited integration Continuously updated Current data values only Predictable retrieval Data Warehouse: a subject-oriented, integrated, time-variant, and nonvolatile collection of data in support of managements decision-making process. Data Mart A monothematic data warehouse Department- oriented or business line oriented Top-Down Approach Advantages A truly corporate effort, an enterprise view of data Inherently architected not a union of disparate data marts Single, central storage of data about the content Centralized rules and control May see quick results if implemented with iterations Disadvantages Takes longer to build even with an iterative method High exposure/risk to failure Needs high level of cross-functional skills High outlay without proof of concept Bottom-Up Approach Advantages Faster and easier implementation of manageable pieces Favorable return on investment and proof of concept Less risk of failure Inherently incremental; can schedule important data marts first Allows project team to learn and grow Disadvantages Each data mart has its own narrow view of data Permeates redundant data in every data mart Perpetuates inconsistent and irreconcilable data Proliferates unmanageable interfaces Data Staging Component Three major functions need to be performed for getting the data ready (ETL) extract the data transform the data and then load the data into the data warehouse storage Data Warehouse Subject-Oriented Data is stored by subjects Integrated Data Need to pull together all the relevant data from the various systems Data from internal operational systems Data from outside sources Time-Variant Data the stored data contains the current values The use needs data not only about the current purchase, but on the past purchases Nonvolatile Data Data from the operational systems are moved into the data warehouse at specific intervals Data Granularity Data granularity in a data warehouse refers to the level of detail The lower the level of detail, the finer the data granularity The lowest level of detail  ® a lot of data in the data warehouse Four steps in dimensional modeling Identify the process being modeled. Determine the grain at which facts will be stored. Choose the dimensions. Identify the numeric measures for the facts. Components of a star schema Fact tables contain factual or quantitative data 1:N relationship between dimension tables and fact tables Dimension tables contain descriptions about the subjects of the business Dimension tables are denormalized to maximize performance Slowly changing dimensions Are the Customer and Product Dim independent of Time Dim? Changes in names, family status, product district/region How to handle these changes in order not to affect the history status? Eg. Insurance 3 suggestions for slowly changing dimensions Type 1 overwrite/erase old values; no accurate tracking of history needed; easy to implement; Type 2 create new record at time of change; partitioning the history (old and new description); Type 3 new current fields, legitimate need to track both old and new states Original and current values; Intermediate Values are lost Junk Dimensions Leave the flags in the fact tables likely sparse data no real browse entry capability can significantly increase the size of the fact table Remove the attributes from the design potentially critical information will be lost if they provide no relevance, remove them Make a flag into its own dimension may greatly increase the number of dimensions, increasing the size of the fact table can clutter and confuse the design Combine all relevant flags, etc. into a single dimension the number of possibilities remain finite information is retained The Monster Dimension It is a compromise Avoids creating copies of dimension records in a significantly large dimension Done to manage space and changes efficiently 3 types of multidimensional data Data from external sources (represented by the blue cylinder) is copied into the small red marble cube, which represents input multidimensional data Pre-calculated, stored results derived from it on-the-fly results, calculated as required at run-time, but not stored in a database Aggregation The system uses physically stored aggregates as a way to enhance performance of common queries. These aggregates, like indexes, are chosen silently by the database if they are physically present. End users and application developers do not need to know what aggregates are available at any point in time, and applications are not required to explicitly code the name of an aggregate When you go for higher level of aggregates, the sparsity percentage goes down, eventually reaching 100% of occupancy Data Extraction Two major types of data extractions from the source operational systems as is (static) data and data of revision as is or static data is the capture of data at a given point in time For initial load Data of revision is known as incremental data capture Data Quality Issues Dummy values in fields Missing data Unofficial use of fields Cryptic values Contradicting values Reused primary keys Inconsistent values Incorrect values Multipurpose fields Steps in Data Cleansing Parsing Correcting Standardizing Matching Consolidating DATA TRANSFORMATION All the extracted data must be made usable in the data warehouse The quality of the data in many old legacy systems is less likely to be good enough for the data warehouse Transformation of source data encompasses a wide variety of manipulations to change all the extracted source data into usable information to be stored in the data warehouse Data warehouse practitioners have attempted to classify data transformations in several ways Basic Tasks Set of basic tasks Selection Splitting/Joining Conversion Summarization Enrichment Loading Initial Load Load mode Incremental Loads Constructive merge mode Type 1 slowly changing dimension: destructive merge mode Full Refresh Load and append modes are applicable OLAP defined: On-line Analytical Processing(OLAP) is a category of software technology that enables analysts, managers and executives to gain insight into data through fast, consistent, interactive access in a wide variety of possible views of information that has been transformed from raw data to reflect the real dimensionality of the enterprise as understood by the user Users need the ability to perform multidimensional analysis with complex calculations The basic virtues of OLAP Enables analysts, executives, and managers to gain useful insights from the presentation of data Can reorganize metrics along several dimensions and allow data to be viewed from different perspectives Supports multidimensional analysis Is able to drill down or roll up within each dimension BUSINESS METADATA Is like a roadmap or an easy-to-use information directory showing the contents and how to get it How can I sign onto and connect with the data warehouse? Which parts of the data warehouse can I access? Can I see all the attributes from a specific table? What are the definitions of the attributes I need in my query? Are there any queries and reports already predefined to give the results I need? TECHNICAL METADATA Technical metadata is meant for the IT staff responsible for the development and administration of the data warehouse Technical metadata is like a support guide for the IT professionals to build, maintain, and administer the data warehouse Physical Design Objectives Improve Performance In OLTP, 1-2 secs max; in DW secs to mins Ensure scalability Manage storage Provide Ease of Administration Design for Flexibility. Physical Design Steps Develop Standards Create Aggregates Plan Determine Data Partitioning Establish Clustering Options Prepare Indexing Strategy Assign storage structures Partitioning Breaking data into several physical units that can be handled separately Not a question of whether to do it in data warehouses but how to do it Granularity and partitioning are key to effective implementation of a warehouse Partitions are spread across multiple disks to boost performance Why Partition? Flexibility in managing data Smaller physical units allow easy restructuring free indexing sequential scans if needed easy reorganization easy recovery easy monitoring Improve performance Criterion for Partitioning Vertically (groups of selected columns together. More typical in dimension tables) Horizontally (e.g. recent events and past history. Typical in fact tables) Parallelization The argument goes: if your main problem is that your queries run too slowly, use more than one machine at a time to make them run faster (Parallel Processing). Oracle uses this strategy in its warehousing products. Indexing Structure separate from the table data it refers to, storing the location of rows in the database based on the column values specified when the index is created. They are used in data warehouse to improve warehouse throughput Indexing and loading Indexing for large tables Btree characteristics: Balanced Bushy: multi-way tree Block-oriented Dynamic Bitmap Index Bitmap indices are a special type of index designed for efficient querying on multiple keys Records in a relation are assumed to be numbered sequentially from, say, 0 Given a number n it must be easy to retrieve record n Particularly easy if records are of fixed size Applicable on attributes that take on a relatively small number of distinct values E.g. gender, country, state, à ¢Ã¢â€š ¬Ã‚ ¦ E.g. income-level (income broken up into a small number of levels such as 0-9999, 10000-19999, 20000-50000, 50000- infinity) A bitmap is simply an array of bits In its simplest form a bitmap index on an attribute has a bitmap for each value of the attribute Bitmap has as many bits as records In a bitmap for value v, the bit for a record is 1 if the record has the value v for the attribute, and is 0 otherwise Clustering The technique involves placing and managing related units of data to be retrieved in the same physical block of storage This arrangement causes related units of data to be retrieved together in one single operation In a clustering index, the order of the rows is close to the index order. Close means that physical records containing rows will not have to be accessed more than one time if the index is accessed sequentially DW Deployment Major deployment activities Complete user acceptance Perform initial loads Get user desktops ready Complete initial user training Institute initial user support Deploy in stages DW Growth Maintenance Monitoring the DW Collection of Stats Usage of Stats For growth planning For fine tuning User training Data Content Applications Tools Dimensional Modeling Exercise Exercise: Create a star schema diagram that will enable FIT-WORLD GYM INC. to analyze their revenue. à ¢Ã‹â€ Ã¢â‚¬â„¢ The fact table will include: for every instance of revenue taken attribute(s) useful for analyzing revenue. à ¢Ã‹â€ Ã¢â‚¬â„¢ The star schema will include all dimensions that can be useful for analyzing revenue. à ¢Ã‹â€ Ã¢â‚¬â„¢ The only data sources available are shown bellow. SOURCE 1 FIT-WORLD GYM Operational Database: ER-Diagram and the tables based on it (with data) SOLUTION

Antidepressants for Postnatal Depression

Antidepressants for Postnatal Depression Antidepressants are they a safe and effective choice for the treatment of postnatal depression? This review assessed the evidence concerning the effectiveness and safety of antidepressants in the management of postnatal depression. This would facilitate evidence-based clinical decisions in the treatment of patients. Data was sourced from several electronic Athens-based and free databases covering the psycho-biomedical and nursing literature. Studies found included randomised clinical trials, case- and cohort-controlled studies, questionnaire surveys, and qualitative/exploratory research. Previous reviews were also appraised. Outcomes from over 1200 mothers, mother-infant pairings, or infants, exposed to antidepressants were considered. Antidepressants appear to significantly alleviate depressive symptoms. Furthermore, the reported side effects are generally benign and clinically insignificant. However, methodological and analytic flaws negate conclusive inferences. Many studies fail to account for important covariates that may explain effects attributed to antidepressants. Furthermore, most studies fail to account for interactions between antidepressants and patient characteristics, which may reveal more severe adverse effects. Additionally, there is a paucity of literature on long-term effects. Finally, a lack of randomised clinical trials precludes inferences of causality. Given these constraints it is recommended that antidepressants are used as a last resort, and patients are closely monitored to identify unexpected side effects, or recovery induced by covariates rather than antidepressants. Chapter One Introduction, Rationale, AIMS Introduction According to Beckford-ball (2000) postnatal depression (PND) fails to attract public attention because it is associated with a positive event – childbirth – notwithstanding the evidence that a sizeable majority of women experience this phenomenon after delivering their baby (RCP , 2004). Nevertheless postnatal depression, if left untreated, can have adverse effects for mother-child relationship and infant development (Green, 1995). This brief reviews evidence concerning the safety and effectiveness of antidepressants for treating postnatal depression. It is argued that while antidepressants may alleviate depressive symptoms, with benign side effects, various methodological and analytic constraints in the literature negate conclusive inferences on the subject. Antidepressants According to the RCP antidepressants are drugs developed in the 1950s for treating symptoms of depression (RCP, 2006).They work by stimulating neurotransmitters in the brain. Three main types of antidepressants are specified: 1. Tricyclic’s (TCAs): amitriptyline, imipramine, nortriptyline. 2. Selective Serotonin Reuptake Inhibitors (SSRIs): sertraline, paroxetine, fluoxetine, citalopram, venlafaxine, moclobemide. 3. Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs): venlafaxine, reboxetine. 4. Monoamine Oxidase Inhibitors (MAOIs): tranylcypromine, moclobemide, phenelzine. The RCP posits that following three months of treatment 50% to 65%of people given an antidepressant show improvements in mood, compared with 25% to 30% of people administered a placebo. Thus, even after accounting for placebo effects, antidepressants still facilitate further recovery from depressive symptoms. TCAs are generally older than SSRIs and are considered to produce more side effects, especially if there is an overdose. However, all four classes of antidepressants are considered to have by-products, such as high blood pressure, anxiety, indigestion, dry mouth, heart tremor, and sleepiness. Most of the adverse effects are considered mild and expected to dissipate after few weeks. The RCP cites evidence of withdrawal symptoms in infants shortly after birth, especially with paroxetine (RCP, 2006). Babies can also receive a minute concentration of antidepressants via breastfeeding (Kohen,2005), albeit the risk of pathology is considered small due to the rapid development of kidneys and livers in infants. Overall, use of antidepressants during breastfeeding is not discouraged. Some pregnant women suffer a recurrence of depressive symptoms, and therefore may need to take antidepressants continually. The National Institute for Clinical Excellence (NICE, 2004) has published guidelines for the treatment of depression. However, there is no special emphasis on pregnancy-related depression. Antenatal and postnatal guidelines are due to be published by 2007 (Green, 2005). Postnatal Depression According to the RCP (2004) postnatal depression (PND) â€Å"is what happens when you become depressed after having a baby† (p.1). It is quite common, affecting circa 10% of newly delivered mothers, and can last for several months or longer if untreated. Symptoms include feeling depressed (unhappy, low, wretched, with symptoms becoming worse at particular times of the day), irritable(heightened sensitivity, especially to benign comments by others),tiredness, sleeplessness (late retirements, early rises), and lack of appetite and interest in sexual intercourse. Many women may feel they are unable to cope with the new situation, or even experience anxiety and detachment towards the infant. Various causes of PND have been identified including a previous history of depression, not having a supportive partner, having a sick infant or premature delivery, losing one’s own mother as a child, and stressful life events (e.g. bereavement, divorce, financial problems) within a short time scale. PND has also been associated with hormonal changes. PND appears to progress through several stages (Beckford-Ball, 2000; Green, 2005): 1. Postpartum ‘blues’; 2. Postnatal depression; 3. Puerperal psychosis. Postpartum ‘blues’ â€Å"is usually a transient phase occurring 3-5 days after the birth of the child, with few or no psychiatric symptoms. This stage is characterised by mood swings, tearfulness, fatigue, lack of concentration, confusion, anxiety and hostility† (p.126). This condition is easily treated using hormone replacement therapy. Postnatal depression is less frequent, and emerges as a deep and protracted ‘sadness’ which â€Å"is much more intense and persistent than postpartum blues and its symptoms rarely subside without help† (p.126).Many mothers may feel insecure, incompetent, irritable, guilty (about feeling sad following a happy event), weight changes, insomnia/hypersomnia, psychomotor retardation/agitation, tiredness, and loss of interest in activities. This condition often results in hospitalisation and treatment with antidepressants and cognitive-behavioural counselling. Puerperal psychosis is a severe mood disorder typified by delusions and hallucinations. This condition is considered a psychiatric emergency, necessitating admission to a psychiatric institution and treatment with antidepressants and other drugs. Rationale Despite clear guidelines regarding the use of antidepressants during pregnancy it is necessary to appraise existing literature on the topic, for several reasons: 1. Limited scope of existing reviews. 2. Identification of gaps and inconsistencies in the literature 3. Verification of current claims and guidelines, for example by the RCP, regarding the management of postnatal depression. Limited scope Previous literature reviews are considered in this brief (see Chapter 3). Most reviews are limited in scope mainly because they focus on studies using a particular research methodology(e.g. Booth et al, 2005), mother-child transmission through breastfeeding (e.g. Cohen, 2005), and effects on depressive symptoms(e.g. Hendricks, 2003; Bennett et al, 2004). Thus, there is a need for an all-inclusive review that offers a broader insight into current literature. Identification of gaps and inconsistencies Previous reviews on the topic have highlighted problems that need to be addressed in future research. However each review is different and new research findings continually emerge that may have implications for previous reviews. For example, past reviews have found little evidence of malformations resulting from SSRI use (e.g. Booth et al, 2005). However, new concerns are starting to emerge regarding various analytic and methodological constraints that negate conclusive inferences about the safety of SSRIs. Verification of current claims The RCP publishes an information guide for the use of antidepressants. Various claims are made regarding safety and efficacy of use during/after pregnancy, consistent with NICE(2004) standards. While most assertions are based on research evidence there is a need for on-going reviews that highlight recent findings and consider their implications for existing guidelines. Some of the key pronouncements and guidelines are as follows: 1. People who take antidepressants show a significant improvement over persons administered a placebo. 2. TCAs and SSRIs are equally effective but the latter (newer drug) is safer because it seems to have fewer side effects. 3. MAOIs can induce high blood pressure given certain (dietary) conditions 4. Babies whose mothers take antidepressants (especially paroxetine) may experience adverse effects. 5. It is best to carry on taking antidepressants while breastfeeding, since only minute amounts will be transferred to the baby. Livers and kidneys develop rapidly in babies only a few weeks old, helping to breakdown and filter antidepressants in the bloodstream. Aim The aim of the current review was to appraise evidence on the safety and effectiveness of antidepressants in the management of PND. Chapter Two Literature Review The evidence/data to be reviewed here is based on a comprehensive search of multiple databases including HIGHWIRE Press, ACADEMIC SEARCH PREMIER (access through EBSCO databases), Psych INFO, INTERNURSE, and the BRITISH MEDICAL JOURNAL database. The Internet was also searched with emphasis on peer-reviewed published journal articles. Key words included: ‘antidepressants’, ‘depression’, and ‘postnatal depression’. There were no problems of access: all the databases reviewed are available to the general public through university library resources and/or Athens protected resources. These particular databases were chosen because of their emphasis on psychological, biomedical, and practice-based literature, and easier access to full-text files. For example, Psych INFO contains more than1,500,000 references to journal articles, books, technical reports, and dissertations, published in numerous countries. As a form of psychopathology, PND is comprehensively addressed. INTERNURSE provides access specifically to the nursing literature and incorporates may key journals (e.g. British Journal of Nursing, Nurse Prescribing, Practice Nursing, and the International Journal of Palliative Nursing). HIGHWIRE Press is one of the two largest archives of free full-text science databases available, providing access to thousands of psych biomedical journal articles and books. ACADEMIC SEARCH PREMIER incorporates over4000 scholarly journals and 3100 peer review articles. These databases were preferred to others such as SCIENCE DIRECT, have a more general emphasis on scientific (rather than clinical, medical) literature, or not provide sufficient access to full-text articles. Only studies that satisfied the following criteria were eligible to be reviewed: 1. Empirical studies using either qualitative or quantitative methods. Thus, this included case studies, questionnaire surveys, retrospective/prospective designs, and randomised controlled trials(RCT). 2. Review articles and meta-analysis, including Cochrane reviews. 3. Focus on the effects of antidepressants on mother and/or child, and with or without breast-feeding. 4. Focus on postnatal depression, at any stage (i.e. postpartum ‘blues’, depression, and puerperal psychosis [Beckford-Ball, 2000]). 5. Focus on mothers perceptions of antidepressants as treatment for postnatal depression. The review also considered bits of literature published by the Department of Health (DOH), National Institute of Clinical Excellence(NICE), and the Royal College of Psychiatrists (RCP). The emphasis was on the role of SSRIs and TCAs albeit some literature on MAOIs and SNRIs was also considered. Individual studies are reviewed first, followed by review articles. Value of conducting a literature review The safety and effectiveness of antidepressants can easily be established by conducting an original empirical study. However, individual studies are severely constrained in scope and will ultimately provide a ‘snap-shot ‘or ‘localised’ insight on the subject. Moreover, scientific knowledge advances from the accumulation of evidence rather than the results of isolated studies, except in cases where there is a virtually no research on a topic, so that the findings of individual studies assume greater importance. Depression as a topic has been heavily researched. Numerous studies have been published on antidepressants and PND. The multiplicity of published literature reviews on antidepressants/PND attests to the abundance of empirical evidence on the topic. Thus, attempting to establish the safety and efficacy of antidepressants on the basis of a single study would still require an understanding of what has been done before and current knowledge on the topic. Otherwise the researcher is in danger of merely reinventing the wheel. Thus, proper scientific protocol dictates that the researcher first begins by reviewing the literature, in order to get a bird’s eye view of the available evidence, identify gaps in the literature, and highlight avenues for further research (Cool can, 1994). Effects of anti-depressants Appleby et al (1997) conducted a randomised control trial to assess the effects of fluoxetine and cognitive-behavioural counselling on postnatal depression. Another aim was to compare fluoxetine and placebo groups, and also drug combinations and counselling. Hitherto there had been a paucity of randomised clinical trials in this area. Appleby et al (1997) question the clinical benefits of using antidepressants, given that prognosis for PND is often good, despite concerns about over-sedation, and other considerations. The study aimed to establish the optimal treatment frond. The antidepressant of interest was the SSRI, fluoxetine. Participants were women identified at an urban health district(Manchester) as being depressed 6-8 weeks post childbirth. They completed the EPDS , and those with sufficiently high scores were interviewed using a revised clinical schedule, to identify cases of significant psychiatric depression. Women with a prior history of depression, substance abuse, severe illness that required hospitalisation, or breastfeeding, were excluded. Participants were randomly assigned to one of four experimental conditions: fluoxetine, placebo, one counselling session, and six counselling sessions. Mood assessments took place at 1, 4, and 12 weeks post-intervention, using the revised interview schedule, EPDS, and Hamilton depression scale. Data was analysed using analysis of variance for repeated measures (to account for the multiple outcome variables).Overall, 188 verified cases of PND were identified, from a sample of2978 women eligible to participate. Of these, 87 took part in the clinical trial. Results revealed significant improvements in all four treatment groups. Fluoxetine produced better improvement compared with the placebo: the percentage (geometric) differences in means scores based on the revised clinical interview schedule was 37.1% (at 4 weeks)and 40.7% (12 weeks). The effect of fluoxetine was not moderated by(i.e. did not interact with) counselling. Improvements in mood occurred within one week of participating in the clinical trial. The authors concluded â€Å"this study shows the effectiveness of both fluoxetine and cognitive-behavioural counselling in the treatment of women found by community based screening to be depressed 6-8 weeks after childbirth† (p.932). The use of a classic experimental design(RCT) permits causal inferences about the impact of an antidepressant. However, the analysis failed to control for potential confounding variables. While Appleby et al (1997) took steps to eliminate extraneous variance, through strict eligibility criteria, it would have been useful to incorporate detailed background information in the analysis (e.g. availability of social support, marital relationship, stressful life events, side-effect profile, history of drug compliance, patient preference [Green, 2005]) to demonstrate the statistical significance of these variables, and the unique contribution of SSRI treatment after controlling for covariates. Thus, analysis of covariance would have been a more appropriate test. Nolan et al (1997) assessed the effect of TCA and SSRI drugs on feta neurodevelopment. The study compared children of mothers who had been prescribed a tricyclic antidepressant during pregnancy, mothers who had taken fluoxetine during pregnancy, and mothers who had not taken antidepressants. Outcomes measures comprised global IQ and language development, assessed from 16 to 18 months postnatal, using age-specific Bailey Scales of Infant Development, McCarthy Scales of Children’s Abilities (measures IQ), and the Rendell Developmental Language Scales. Results revealed no significant group differences in any of the outcome variables, suggesting that in utero ingestion of either TCAs or fluoxetine does not impair cognitive, linguistic, or behavioural development in infants. Null man et al (2002) conducted follow-up prospective controlled study assessing the effects of TCA and fluoxetine use throughout pregnancy on child development. Three groups of mother-child pairs were recruited. The first two groups were drawn from the Mothers Program, a scheme that provides support to women suffering from major depression. All women recruited from this programme had received counselling under the scheme, with either TCA Rossi (fluoxetine) treatment, which had been maintained throughout the duration of the pregnancy. A comparison group was also recruited that comprised women with no history of psychopathology, depression (based on the Centre for Epidemiological Studies Depression Scale [CES-D]), exposure to chemical or radiation pollution, or severe health problems likely to affect fatal development. This group was randomly selected from among visitors to the author’s clinic. Women who had discontinued the use of antidepressants after conception or during the pregnancy were not eligible to participate. Women were also excluded from the comparison group based on the same criteria applied to the Mothers groups. Outcome data was collected using the CES-D, antenatal and postnatal assessments, neurobehavioral tests (Bailey Scales of Infant Development, McCarthy Scales of Children’s Abilities, age-appropriate Achenbach Child Behaviour Checklist), and follow-up testing of them other (Wechsler Adult Intelligence Scale, and other measures). A one-way analysis of variance was used to compare outcome measures across the three groups. Correlational and regression tests were used to assess the contribution of confounding variables. Results revealed no group differences in child’s global IQ, language development, or behaviour (see Figure 1). The authors concluded, â€Å"Exposure to tricyclic antidepressants or fluoxetine throughout the gestation period does not appear to adversely affect cognition, language development, or the temperament of preschool and early-school children. Although regression was used to account for the contribution of confounding factors, such as verbal comprehension and expressive language, the variance explained by these variables was not in fact partial led out before testing for group differences. This would have required a multivariate analysis of covariance in which adjustments for covariates are built into the analysis. More importantly, the observed similarity in outcomes across the three groups may reflect simple or complex interactions with other variables. This issue is discussed in greater detail in Chapter 3. Figure 1 Cognitive outcomes (mental and psychomotor development, and cognitive abilities) across antidepressant and control groups(Nolan et al, 2002). Differences are not significant. Wisner et al (2001) performed a double-blind randomised control trial to assess the effect of nortriptyline on the rate of reoccurrence of postpartum depression in non-depressed women who had previously had at least one depressive episode. Women were randomly exposed tonortriptyline or a placebo immediately after childbirth. Outcome data was collected over a 5-month period using the Hamilton Rating Scale for Depression, and Research Diagnostic Criteria for depression. No group differences emerged, suggesting that nortriptyline was no more effective than a placebo in treating PND. This study was followed up with another RCT (Wisner et al, 2004), this time evaluating the effect of sertraline on the rate of and time to reoccurrence of postpartum depression. They highlighted a paucity of clinical trials on the impact of antidepressants in women who have previously had a depressive episode, and hence may be prone to experience a reoccurrence. Participants were pregnant women with gestation periods of 9 months or less, and at least one episode of postpartum depression that fits that the DSM-IV definition of major depression. Women with other forms of psychopathology (e.g. psychosis, or bipolar disorder) were excluded. Participants were randomly assigned to a treatment (sertraline) or placebo group. The drug was administered immediately after birth, beginning with a 50mg/day dose, which was later dropped to 25mg/day to minimise side effects (e.g. headache). Data analysis using Fisher’s exact test showed a significant group difference in rate of reoccurrences, during a 17-week preventive treatment period. Reoccurrences occurred in 4/8 women assigned to the placebo group, and1/14 women in the treatment condition, translating into a 0.43difference in reoccurrence rates. All women had adhered to the treatment regime, thus minimising the confounded effect of on-compliance. There was also a significant group difference in time to reoccurrence, with first reoccurrence beginning much earlier for the placebo group (at 5 weeks, followed by more reoccurrences) compared with the treatment group (at 17 weeks, followed by more reoccurrences). However, the treatment group reported more side effects (e.g. Dizziness, drowsiness). This RCT clearly demonstrates the effectiveness of an SSRI in preventing the reoccurrence of postpartum depression, albeit the conclusiveness of these findings is constrained by the failure to control for key background variables, such as previous and recent history of psychopathology, and drug effect expectations. For example, lingering symptoms of a distant depressive episode may help precipitate a quicker reoccurrence. Figure 2 Rate of recurrence of postpartum depression in placebo and SSRI women (Wisner et al, 2004) Oberlander et al (2005) tested the effect of SSRI exposure on bio behavioural responses to acute procedural pain in new-born babies at2 months of age. Previous research has suggested altered behavioural and physiological reactions to a routine painful event in infants, after prenatal exposure to SSRI antidepressants. There is paucity of literature on the long-term effects of SSRIs on neuro behavioural variables, such as cognitive, language and motor development. Given that SSRIs work by inhibiting the reuptake of serotonin(5-hydroxytrypamine [5HT], a neurotransmitter that regulates cardiovascular function and pain signals in the developing brain), and given that SSRIs easily pass through the placenta, it is possible that regions of the brain associated with pain reactivity may be affected. Participants were recruited from a cohort of mothers and their infants during pregnancy, as part of a longitudinal study of prenatal medication use. Only Mothers/infants with no psychotropic or antidepressant use during pregnancy, whose pregnancy was 9 to 10 weeks, and no history of maternal mental illness, were eligible to be assigned to the control group. Three groups of infants were compared: (a) infants exposed to prenatal SSRI (fluoxetine); (b) infants exposed postnatal via breastfeeding(paroxetine, fluoxetine, sertraline); and (c) control infants. Behavioural (facial activity), physiological (variations in heart rate[HR], often used as a measure of pain reactivity in infants), and pharmacological (analysis of blood and breast milk samples) data was collected. Results showed impaired facial reactions in infants exposed to prenatal SSRI. Altered pain reactivity was observed in both prenatal and postnatal exposed infants, suggesting enduring neuro behavioural SSRI effects that extend beyond the new-born phase. Oberlander et all’s(2005) study was constrained by low power and generalizability (limited sample size), and lack of a non-medicated control group with depressive symptomatology. They were uncertain about the clinical implications of these findings, suggesting that use of SSRIs for treating maternal depression was appropriate pending further research on the sustained effects of SSRIs. Marcus et al (2005) screened prenatal depression in pregnant women attending an obstetrics clinic. The study aimed to assess the rates faint-depressant use and its association with depression, measured byte Centre for Epidemiological Studies Depression Scale (CES-D).Overall, 390 women who had used antidepressants within two years of conception were screened. Average age was 28.6 years, and most women were married and Caucasian (73%). Screening took place at around 24gestation weeks. Data was collected regarding the use of antidepressants during the past two years, and discontinued use following pregnancy, in addition to the CES-D data. The standard CES-Duct-off of 16 was used to establish the presence of depressive symptomatology. A t-Test was used to compare two groups: women who reported they stopped using anti-depressants and hence were not currently on medication (n=248); and women who continued to use antidepressants during pregnancy (n=68). The dependent/outcome variable was total CES-Scores. Chi-square was also used to assess use/non-use of antidepressant medication and CES-D groupings (i.e. Figure 3 CES-D data for women who did and those who did not use antidepressants during pregnancy (Marcus et al, 2005). Observed differences are not significant. The authors attributed the null results to poor treatment adherence, and inadequate prescribing/monitoring. Furthermore, they suggested that group differences might have been more pronounced if the study focused on unmediated women (i.e. those who had not used antidepressants at all, rather discontinued use). This study was unique because it assessed antidepressant use around the time of conception. However, the findings are compromised by several analytic constraints. Firstly, these of a t-Test is questionable. This test makes no provision for controlling for covariates (i.e. important background variables, such as patient preference, compliance history, side-effect profile, social support, quality of marital relationship, prior history depression)that may confound significant group differences, although this concerns less important given the null results. A more serious problem is the possibility that certain assumptions which underlie use of the t-Test were violated, notably homogeneity of variance. The huge disparity in group sizes (268 versus 68) hugely increases the possibility of significant differences in group variances, which in turn would obscure reliable differences in CES-Scores. The authors do not report Levine test results, which would have addressed the homogeneity issue. Perhaps a non-parametric test (e.g. Mann-Whitney) may have been more appropriate. Furthermore, it is not clear why the authors conducted a chi-square test! Collapsing the CES-Scores into a dichotomy reduces the quality of the data because it obscures subtle differences between scores. Overall, the chi-square analyses amounted to a less precise duplication of the t-Test results! Finally, this study was entirely based on women’s self-reports of medication use, with no familial, clinical, or other verification. Its therefore unclear to what extent the null results are attributable to self-report bias. Several review articles on antidepressants and postnatal depression have been published. These range from limited commentaries (e.g. Goldstein Sun dell, 1999; Yoshida et al, 1999; Misery Kostas’s, 2002; Hendricks, 2003; Bennett et al, 2004; Cohen, 2005;Marcus et al, 2005) to comprehensive and systematic appraisals. Goldstein and Sun dell (1999) reviewed literature on the safety of SSRIs during pregnancy. Their work was based on the premise that although antidepressants may be necessary during pregnancy it is essential identify and weigh the risks against the benefits in order to make an informed choice as to whether or not to use the drugs. Due to the paucity of randomised controlled trials on the topic, the review focused on evidence obtained from cohort/case-controlled studies, patient surveys, retrospective studies, and anecdotal reports. Electronic databases searched included Medline, EMBASE, Daren’t Drug File, and Psych INFO. Four cohort-controlled and 5 prospective studies were found which evaluated the impact of SSRI exposure. One study compared fluoxetine, TCA, and non-teratogen (e.g. antibiotics) exposed groups of non-depressed females. SSRI and TCA exposure produced no significant malformations, or differences in birth weight and infant prematurity. However, there was a greater tendency for fluoxetine- and tricyclic-exposed women to miscarry compared with controls. However, this effect was not significant and hence may simply have occurred by chance. Goldstein and Sun dell (1999) report another study which compared early exposed (prior to 25 weeks), late exposed (continuing after 24 weeks),and a non-teratogen control group. Again findings revealed no adverse effects in the treatment groups, albeit infants exposed to fluoxetine early showed a higher prevalence of minor anomalies that have little or no clinical importance. Furthermore late exposure to fluoxetine seemed to increase the rates of admission to special care nurseries and impaired fatal development. However, these findings were inconclusive due to prior group differences on previous psychotropic drug use, and failure to control for depression levels. Still other research suggests no effect of SSRIs (sertraline) on the prevalence of stillbirth, prematurity, mean birth weight and gestational age. Evidence suggests no statistically significant differences between SSRI exposed and control groups on IQ, language development, height, and head circumference. Of the prospective studies reviewed three assessed paroxetine, and fluoxetine, and two tested sertraline. All studies reported no significant increase in the rate of malformations and spontaneous abortion, although there was some evidence of lower birth weight given protracted use of antidepressants. Goldstein and Sun dell (1999) found one study, which showed that fluoxetine exposure during the first trimester did not increase the risk of malformations Antidepressants for Postnatal Depression Antidepressants for Postnatal Depression Antidepressants are they a safe and effective choice for the treatment of postnatal depression? This review assessed the evidence concerning the effectiveness and safety of antidepressants in the management of postnatal depression. This would facilitate evidence-based clinical decisions in the treatment of patients. Data was sourced from several electronic Athens-based and free databases covering the psycho-biomedical and nursing literature. Studies found included randomised clinical trials, case- and cohort-controlled studies, questionnaire surveys, and qualitative/exploratory research. Previous reviews were also appraised. Outcomes from over 1200 mothers, mother-infant pairings, or infants, exposed to antidepressants were considered. Antidepressants appear to significantly alleviate depressive symptoms. Furthermore, the reported side effects are generally benign and clinically insignificant. However, methodological and analytic flaws negate conclusive inferences. Many studies fail to account for important covariates that may explain effects attributed to antidepressants. Furthermore, most studies fail to account for interactions between antidepressants and patient characteristics, which may reveal more severe adverse effects. Additionally, there is a paucity of literature on long-term effects. Finally, a lack of randomised clinical trials precludes inferences of causality. Given these constraints it is recommended that antidepressants are used as a last resort, and patients are closely monitored to identify unexpected side effects, or recovery induced by covariates rather than antidepressants. Chapter One Introduction, Rationale, AIMS Introduction According to Beckford-ball (2000) postnatal depression (PND) fails to attract public attention because it is associated with a positive event – childbirth – notwithstanding the evidence that a sizeable majority of women experience this phenomenon after delivering their baby (RCP , 2004). Nevertheless postnatal depression, if left untreated, can have adverse effects for mother-child relationship and infant development (Green, 1995). This brief reviews evidence concerning the safety and effectiveness of antidepressants for treating postnatal depression. It is argued that while antidepressants may alleviate depressive symptoms, with benign side effects, various methodological and analytic constraints in the literature negate conclusive inferences on the subject. Antidepressants According to the RCP antidepressants are drugs developed in the 1950s for treating symptoms of depression (RCP, 2006).They work by stimulating neurotransmitters in the brain. Three main types of antidepressants are specified: 1. Tricyclic’s (TCAs): amitriptyline, imipramine, nortriptyline. 2. Selective Serotonin Reuptake Inhibitors (SSRIs): sertraline, paroxetine, fluoxetine, citalopram, venlafaxine, moclobemide. 3. Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs): venlafaxine, reboxetine. 4. Monoamine Oxidase Inhibitors (MAOIs): tranylcypromine, moclobemide, phenelzine. The RCP posits that following three months of treatment 50% to 65%of people given an antidepressant show improvements in mood, compared with 25% to 30% of people administered a placebo. Thus, even after accounting for placebo effects, antidepressants still facilitate further recovery from depressive symptoms. TCAs are generally older than SSRIs and are considered to produce more side effects, especially if there is an overdose. However, all four classes of antidepressants are considered to have by-products, such as high blood pressure, anxiety, indigestion, dry mouth, heart tremor, and sleepiness. Most of the adverse effects are considered mild and expected to dissipate after few weeks. The RCP cites evidence of withdrawal symptoms in infants shortly after birth, especially with paroxetine (RCP, 2006). Babies can also receive a minute concentration of antidepressants via breastfeeding (Kohen,2005), albeit the risk of pathology is considered small due to the rapid development of kidneys and livers in infants. Overall, use of antidepressants during breastfeeding is not discouraged. Some pregnant women suffer a recurrence of depressive symptoms, and therefore may need to take antidepressants continually. The National Institute for Clinical Excellence (NICE, 2004) has published guidelines for the treatment of depression. However, there is no special emphasis on pregnancy-related depression. Antenatal and postnatal guidelines are due to be published by 2007 (Green, 2005). Postnatal Depression According to the RCP (2004) postnatal depression (PND) â€Å"is what happens when you become depressed after having a baby† (p.1). It is quite common, affecting circa 10% of newly delivered mothers, and can last for several months or longer if untreated. Symptoms include feeling depressed (unhappy, low, wretched, with symptoms becoming worse at particular times of the day), irritable(heightened sensitivity, especially to benign comments by others),tiredness, sleeplessness (late retirements, early rises), and lack of appetite and interest in sexual intercourse. Many women may feel they are unable to cope with the new situation, or even experience anxiety and detachment towards the infant. Various causes of PND have been identified including a previous history of depression, not having a supportive partner, having a sick infant or premature delivery, losing one’s own mother as a child, and stressful life events (e.g. bereavement, divorce, financial problems) within a short time scale. PND has also been associated with hormonal changes. PND appears to progress through several stages (Beckford-Ball, 2000; Green, 2005): 1. Postpartum ‘blues’; 2. Postnatal depression; 3. Puerperal psychosis. Postpartum ‘blues’ â€Å"is usually a transient phase occurring 3-5 days after the birth of the child, with few or no psychiatric symptoms. This stage is characterised by mood swings, tearfulness, fatigue, lack of concentration, confusion, anxiety and hostility† (p.126). This condition is easily treated using hormone replacement therapy. Postnatal depression is less frequent, and emerges as a deep and protracted ‘sadness’ which â€Å"is much more intense and persistent than postpartum blues and its symptoms rarely subside without help† (p.126).Many mothers may feel insecure, incompetent, irritable, guilty (about feeling sad following a happy event), weight changes, insomnia/hypersomnia, psychomotor retardation/agitation, tiredness, and loss of interest in activities. This condition often results in hospitalisation and treatment with antidepressants and cognitive-behavioural counselling. Puerperal psychosis is a severe mood disorder typified by delusions and hallucinations. This condition is considered a psychiatric emergency, necessitating admission to a psychiatric institution and treatment with antidepressants and other drugs. Rationale Despite clear guidelines regarding the use of antidepressants during pregnancy it is necessary to appraise existing literature on the topic, for several reasons: 1. Limited scope of existing reviews. 2. Identification of gaps and inconsistencies in the literature 3. Verification of current claims and guidelines, for example by the RCP, regarding the management of postnatal depression. Limited scope Previous literature reviews are considered in this brief (see Chapter 3). Most reviews are limited in scope mainly because they focus on studies using a particular research methodology(e.g. Booth et al, 2005), mother-child transmission through breastfeeding (e.g. Cohen, 2005), and effects on depressive symptoms(e.g. Hendricks, 2003; Bennett et al, 2004). Thus, there is a need for an all-inclusive review that offers a broader insight into current literature. Identification of gaps and inconsistencies Previous reviews on the topic have highlighted problems that need to be addressed in future research. However each review is different and new research findings continually emerge that may have implications for previous reviews. For example, past reviews have found little evidence of malformations resulting from SSRI use (e.g. Booth et al, 2005). However, new concerns are starting to emerge regarding various analytic and methodological constraints that negate conclusive inferences about the safety of SSRIs. Verification of current claims The RCP publishes an information guide for the use of antidepressants. Various claims are made regarding safety and efficacy of use during/after pregnancy, consistent with NICE(2004) standards. While most assertions are based on research evidence there is a need for on-going reviews that highlight recent findings and consider their implications for existing guidelines. Some of the key pronouncements and guidelines are as follows: 1. People who take antidepressants show a significant improvement over persons administered a placebo. 2. TCAs and SSRIs are equally effective but the latter (newer drug) is safer because it seems to have fewer side effects. 3. MAOIs can induce high blood pressure given certain (dietary) conditions 4. Babies whose mothers take antidepressants (especially paroxetine) may experience adverse effects. 5. It is best to carry on taking antidepressants while breastfeeding, since only minute amounts will be transferred to the baby. Livers and kidneys develop rapidly in babies only a few weeks old, helping to breakdown and filter antidepressants in the bloodstream. Aim The aim of the current review was to appraise evidence on the safety and effectiveness of antidepressants in the management of PND. Chapter Two Literature Review The evidence/data to be reviewed here is based on a comprehensive search of multiple databases including HIGHWIRE Press, ACADEMIC SEARCH PREMIER (access through EBSCO databases), Psych INFO, INTERNURSE, and the BRITISH MEDICAL JOURNAL database. The Internet was also searched with emphasis on peer-reviewed published journal articles. Key words included: ‘antidepressants’, ‘depression’, and ‘postnatal depression’. There were no problems of access: all the databases reviewed are available to the general public through university library resources and/or Athens protected resources. These particular databases were chosen because of their emphasis on psychological, biomedical, and practice-based literature, and easier access to full-text files. For example, Psych INFO contains more than1,500,000 references to journal articles, books, technical reports, and dissertations, published in numerous countries. As a form of psychopathology, PND is comprehensively addressed. INTERNURSE provides access specifically to the nursing literature and incorporates may key journals (e.g. British Journal of Nursing, Nurse Prescribing, Practice Nursing, and the International Journal of Palliative Nursing). HIGHWIRE Press is one of the two largest archives of free full-text science databases available, providing access to thousands of psych biomedical journal articles and books. ACADEMIC SEARCH PREMIER incorporates over4000 scholarly journals and 3100 peer review articles. These databases were preferred to others such as SCIENCE DIRECT, have a more general emphasis on scientific (rather than clinical, medical) literature, or not provide sufficient access to full-text articles. Only studies that satisfied the following criteria were eligible to be reviewed: 1. Empirical studies using either qualitative or quantitative methods. Thus, this included case studies, questionnaire surveys, retrospective/prospective designs, and randomised controlled trials(RCT). 2. Review articles and meta-analysis, including Cochrane reviews. 3. Focus on the effects of antidepressants on mother and/or child, and with or without breast-feeding. 4. Focus on postnatal depression, at any stage (i.e. postpartum ‘blues’, depression, and puerperal psychosis [Beckford-Ball, 2000]). 5. Focus on mothers perceptions of antidepressants as treatment for postnatal depression. The review also considered bits of literature published by the Department of Health (DOH), National Institute of Clinical Excellence(NICE), and the Royal College of Psychiatrists (RCP). The emphasis was on the role of SSRIs and TCAs albeit some literature on MAOIs and SNRIs was also considered. Individual studies are reviewed first, followed by review articles. Value of conducting a literature review The safety and effectiveness of antidepressants can easily be established by conducting an original empirical study. However, individual studies are severely constrained in scope and will ultimately provide a ‘snap-shot ‘or ‘localised’ insight on the subject. Moreover, scientific knowledge advances from the accumulation of evidence rather than the results of isolated studies, except in cases where there is a virtually no research on a topic, so that the findings of individual studies assume greater importance. Depression as a topic has been heavily researched. Numerous studies have been published on antidepressants and PND. The multiplicity of published literature reviews on antidepressants/PND attests to the abundance of empirical evidence on the topic. Thus, attempting to establish the safety and efficacy of antidepressants on the basis of a single study would still require an understanding of what has been done before and current knowledge on the topic. Otherwise the researcher is in danger of merely reinventing the wheel. Thus, proper scientific protocol dictates that the researcher first begins by reviewing the literature, in order to get a bird’s eye view of the available evidence, identify gaps in the literature, and highlight avenues for further research (Cool can, 1994). Effects of anti-depressants Appleby et al (1997) conducted a randomised control trial to assess the effects of fluoxetine and cognitive-behavioural counselling on postnatal depression. Another aim was to compare fluoxetine and placebo groups, and also drug combinations and counselling. Hitherto there had been a paucity of randomised clinical trials in this area. Appleby et al (1997) question the clinical benefits of using antidepressants, given that prognosis for PND is often good, despite concerns about over-sedation, and other considerations. The study aimed to establish the optimal treatment frond. The antidepressant of interest was the SSRI, fluoxetine. Participants were women identified at an urban health district(Manchester) as being depressed 6-8 weeks post childbirth. They completed the EPDS , and those with sufficiently high scores were interviewed using a revised clinical schedule, to identify cases of significant psychiatric depression. Women with a prior history of depression, substance abuse, severe illness that required hospitalisation, or breastfeeding, were excluded. Participants were randomly assigned to one of four experimental conditions: fluoxetine, placebo, one counselling session, and six counselling sessions. Mood assessments took place at 1, 4, and 12 weeks post-intervention, using the revised interview schedule, EPDS, and Hamilton depression scale. Data was analysed using analysis of variance for repeated measures (to account for the multiple outcome variables).Overall, 188 verified cases of PND were identified, from a sample of2978 women eligible to participate. Of these, 87 took part in the clinical trial. Results revealed significant improvements in all four treatment groups. Fluoxetine produced better improvement compared with the placebo: the percentage (geometric) differences in means scores based on the revised clinical interview schedule was 37.1% (at 4 weeks)and 40.7% (12 weeks). The effect of fluoxetine was not moderated by(i.e. did not interact with) counselling. Improvements in mood occurred within one week of participating in the clinical trial. The authors concluded â€Å"this study shows the effectiveness of both fluoxetine and cognitive-behavioural counselling in the treatment of women found by community based screening to be depressed 6-8 weeks after childbirth† (p.932). The use of a classic experimental design(RCT) permits causal inferences about the impact of an antidepressant. However, the analysis failed to control for potential confounding variables. While Appleby et al (1997) took steps to eliminate extraneous variance, through strict eligibility criteria, it would have been useful to incorporate detailed background information in the analysis (e.g. availability of social support, marital relationship, stressful life events, side-effect profile, history of drug compliance, patient preference [Green, 2005]) to demonstrate the statistical significance of these variables, and the unique contribution of SSRI treatment after controlling for covariates. Thus, analysis of covariance would have been a more appropriate test. Nolan et al (1997) assessed the effect of TCA and SSRI drugs on feta neurodevelopment. The study compared children of mothers who had been prescribed a tricyclic antidepressant during pregnancy, mothers who had taken fluoxetine during pregnancy, and mothers who had not taken antidepressants. Outcomes measures comprised global IQ and language development, assessed from 16 to 18 months postnatal, using age-specific Bailey Scales of Infant Development, McCarthy Scales of Children’s Abilities (measures IQ), and the Rendell Developmental Language Scales. Results revealed no significant group differences in any of the outcome variables, suggesting that in utero ingestion of either TCAs or fluoxetine does not impair cognitive, linguistic, or behavioural development in infants. Null man et al (2002) conducted follow-up prospective controlled study assessing the effects of TCA and fluoxetine use throughout pregnancy on child development. Three groups of mother-child pairs were recruited. The first two groups were drawn from the Mothers Program, a scheme that provides support to women suffering from major depression. All women recruited from this programme had received counselling under the scheme, with either TCA Rossi (fluoxetine) treatment, which had been maintained throughout the duration of the pregnancy. A comparison group was also recruited that comprised women with no history of psychopathology, depression (based on the Centre for Epidemiological Studies Depression Scale [CES-D]), exposure to chemical or radiation pollution, or severe health problems likely to affect fatal development. This group was randomly selected from among visitors to the author’s clinic. Women who had discontinued the use of antidepressants after conception or during the pregnancy were not eligible to participate. Women were also excluded from the comparison group based on the same criteria applied to the Mothers groups. Outcome data was collected using the CES-D, antenatal and postnatal assessments, neurobehavioral tests (Bailey Scales of Infant Development, McCarthy Scales of Children’s Abilities, age-appropriate Achenbach Child Behaviour Checklist), and follow-up testing of them other (Wechsler Adult Intelligence Scale, and other measures). A one-way analysis of variance was used to compare outcome measures across the three groups. Correlational and regression tests were used to assess the contribution of confounding variables. Results revealed no group differences in child’s global IQ, language development, or behaviour (see Figure 1). The authors concluded, â€Å"Exposure to tricyclic antidepressants or fluoxetine throughout the gestation period does not appear to adversely affect cognition, language development, or the temperament of preschool and early-school children. Although regression was used to account for the contribution of confounding factors, such as verbal comprehension and expressive language, the variance explained by these variables was not in fact partial led out before testing for group differences. This would have required a multivariate analysis of covariance in which adjustments for covariates are built into the analysis. More importantly, the observed similarity in outcomes across the three groups may reflect simple or complex interactions with other variables. This issue is discussed in greater detail in Chapter 3. Figure 1 Cognitive outcomes (mental and psychomotor development, and cognitive abilities) across antidepressant and control groups(Nolan et al, 2002). Differences are not significant. Wisner et al (2001) performed a double-blind randomised control trial to assess the effect of nortriptyline on the rate of reoccurrence of postpartum depression in non-depressed women who had previously had at least one depressive episode. Women were randomly exposed tonortriptyline or a placebo immediately after childbirth. Outcome data was collected over a 5-month period using the Hamilton Rating Scale for Depression, and Research Diagnostic Criteria for depression. No group differences emerged, suggesting that nortriptyline was no more effective than a placebo in treating PND. This study was followed up with another RCT (Wisner et al, 2004), this time evaluating the effect of sertraline on the rate of and time to reoccurrence of postpartum depression. They highlighted a paucity of clinical trials on the impact of antidepressants in women who have previously had a depressive episode, and hence may be prone to experience a reoccurrence. Participants were pregnant women with gestation periods of 9 months or less, and at least one episode of postpartum depression that fits that the DSM-IV definition of major depression. Women with other forms of psychopathology (e.g. psychosis, or bipolar disorder) were excluded. Participants were randomly assigned to a treatment (sertraline) or placebo group. The drug was administered immediately after birth, beginning with a 50mg/day dose, which was later dropped to 25mg/day to minimise side effects (e.g. headache). Data analysis using Fisher’s exact test showed a significant group difference in rate of reoccurrences, during a 17-week preventive treatment period. Reoccurrences occurred in 4/8 women assigned to the placebo group, and1/14 women in the treatment condition, translating into a 0.43difference in reoccurrence rates. All women had adhered to the treatment regime, thus minimising the confounded effect of on-compliance. There was also a significant group difference in time to reoccurrence, with first reoccurrence beginning much earlier for the placebo group (at 5 weeks, followed by more reoccurrences) compared with the treatment group (at 17 weeks, followed by more reoccurrences). However, the treatment group reported more side effects (e.g. Dizziness, drowsiness). This RCT clearly demonstrates the effectiveness of an SSRI in preventing the reoccurrence of postpartum depression, albeit the conclusiveness of these findings is constrained by the failure to control for key background variables, such as previous and recent history of psychopathology, and drug effect expectations. For example, lingering symptoms of a distant depressive episode may help precipitate a quicker reoccurrence. Figure 2 Rate of recurrence of postpartum depression in placebo and SSRI women (Wisner et al, 2004) Oberlander et al (2005) tested the effect of SSRI exposure on bio behavioural responses to acute procedural pain in new-born babies at2 months of age. Previous research has suggested altered behavioural and physiological reactions to a routine painful event in infants, after prenatal exposure to SSRI antidepressants. There is paucity of literature on the long-term effects of SSRIs on neuro behavioural variables, such as cognitive, language and motor development. Given that SSRIs work by inhibiting the reuptake of serotonin(5-hydroxytrypamine [5HT], a neurotransmitter that regulates cardiovascular function and pain signals in the developing brain), and given that SSRIs easily pass through the placenta, it is possible that regions of the brain associated with pain reactivity may be affected. Participants were recruited from a cohort of mothers and their infants during pregnancy, as part of a longitudinal study of prenatal medication use. Only Mothers/infants with no psychotropic or antidepressant use during pregnancy, whose pregnancy was 9 to 10 weeks, and no history of maternal mental illness, were eligible to be assigned to the control group. Three groups of infants were compared: (a) infants exposed to prenatal SSRI (fluoxetine); (b) infants exposed postnatal via breastfeeding(paroxetine, fluoxetine, sertraline); and (c) control infants. Behavioural (facial activity), physiological (variations in heart rate[HR], often used as a measure of pain reactivity in infants), and pharmacological (analysis of blood and breast milk samples) data was collected. Results showed impaired facial reactions in infants exposed to prenatal SSRI. Altered pain reactivity was observed in both prenatal and postnatal exposed infants, suggesting enduring neuro behavioural SSRI effects that extend beyond the new-born phase. Oberlander et all’s(2005) study was constrained by low power and generalizability (limited sample size), and lack of a non-medicated control group with depressive symptomatology. They were uncertain about the clinical implications of these findings, suggesting that use of SSRIs for treating maternal depression was appropriate pending further research on the sustained effects of SSRIs. Marcus et al (2005) screened prenatal depression in pregnant women attending an obstetrics clinic. The study aimed to assess the rates faint-depressant use and its association with depression, measured byte Centre for Epidemiological Studies Depression Scale (CES-D).Overall, 390 women who had used antidepressants within two years of conception were screened. Average age was 28.6 years, and most women were married and Caucasian (73%). Screening took place at around 24gestation weeks. Data was collected regarding the use of antidepressants during the past two years, and discontinued use following pregnancy, in addition to the CES-D data. The standard CES-Duct-off of 16 was used to establish the presence of depressive symptomatology. A t-Test was used to compare two groups: women who reported they stopped using anti-depressants and hence were not currently on medication (n=248); and women who continued to use antidepressants during pregnancy (n=68). The dependent/outcome variable was total CES-Scores. Chi-square was also used to assess use/non-use of antidepressant medication and CES-D groupings (i.e. Figure 3 CES-D data for women who did and those who did not use antidepressants during pregnancy (Marcus et al, 2005). Observed differences are not significant. The authors attributed the null results to poor treatment adherence, and inadequate prescribing/monitoring. Furthermore, they suggested that group differences might have been more pronounced if the study focused on unmediated women (i.e. those who had not used antidepressants at all, rather discontinued use). This study was unique because it assessed antidepressant use around the time of conception. However, the findings are compromised by several analytic constraints. Firstly, these of a t-Test is questionable. This test makes no provision for controlling for covariates (i.e. important background variables, such as patient preference, compliance history, side-effect profile, social support, quality of marital relationship, prior history depression)that may confound significant group differences, although this concerns less important given the null results. A more serious problem is the possibility that certain assumptions which underlie use of the t-Test were violated, notably homogeneity of variance. The huge disparity in group sizes (268 versus 68) hugely increases the possibility of significant differences in group variances, which in turn would obscure reliable differences in CES-Scores. The authors do not report Levine test results, which would have addressed the homogeneity issue. Perhaps a non-parametric test (e.g. Mann-Whitney) may have been more appropriate. Furthermore, it is not clear why the authors conducted a chi-square test! Collapsing the CES-Scores into a dichotomy reduces the quality of the data because it obscures subtle differences between scores. Overall, the chi-square analyses amounted to a less precise duplication of the t-Test results! Finally, this study was entirely based on women’s self-reports of medication use, with no familial, clinical, or other verification. Its therefore unclear to what extent the null results are attributable to self-report bias. Several review articles on antidepressants and postnatal depression have been published. These range from limited commentaries (e.g. Goldstein Sun dell, 1999; Yoshida et al, 1999; Misery Kostas’s, 2002; Hendricks, 2003; Bennett et al, 2004; Cohen, 2005;Marcus et al, 2005) to comprehensive and systematic appraisals. Goldstein and Sun dell (1999) reviewed literature on the safety of SSRIs during pregnancy. Their work was based on the premise that although antidepressants may be necessary during pregnancy it is essential identify and weigh the risks against the benefits in order to make an informed choice as to whether or not to use the drugs. Due to the paucity of randomised controlled trials on the topic, the review focused on evidence obtained from cohort/case-controlled studies, patient surveys, retrospective studies, and anecdotal reports. Electronic databases searched included Medline, EMBASE, Daren’t Drug File, and Psych INFO. Four cohort-controlled and 5 prospective studies were found which evaluated the impact of SSRI exposure. One study compared fluoxetine, TCA, and non-teratogen (e.g. antibiotics) exposed groups of non-depressed females. SSRI and TCA exposure produced no significant malformations, or differences in birth weight and infant prematurity. However, there was a greater tendency for fluoxetine- and tricyclic-exposed women to miscarry compared with controls. However, this effect was not significant and hence may simply have occurred by chance. Goldstein and Sun dell (1999) report another study which compared early exposed (prior to 25 weeks), late exposed (continuing after 24 weeks),and a non-teratogen control group. Again findings revealed no adverse effects in the treatment groups, albeit infants exposed to fluoxetine early showed a higher prevalence of minor anomalies that have little or no clinical importance. Furthermore late exposure to fluoxetine seemed to increase the rates of admission to special care nurseries and impaired fatal development. However, these findings were inconclusive due to prior group differences on previous psychotropic drug use, and failure to control for depression levels. Still other research suggests no effect of SSRIs (sertraline) on the prevalence of stillbirth, prematurity, mean birth weight and gestational age. Evidence suggests no statistically significant differences between SSRI exposed and control groups on IQ, language development, height, and head circumference. Of the prospective studies reviewed three assessed paroxetine, and fluoxetine, and two tested sertraline. All studies reported no significant increase in the rate of malformations and spontaneous abortion, although there was some evidence of lower birth weight given protracted use of antidepressants. Goldstein and Sun dell (1999) found one study, which showed that fluoxetine exposure during the first trimester did not increase the risk of malformations