On the Absence of Self-Control as the Basis for a General Theory of Crime Essay

Self-control theory theorizes the single most important factor behind crime is an individual’s lack of self-control. This is explored and explained much more in-depth in A General Theory of Crime. In this book, Gottfredson and Hirschi theorized that low self-control is the root to all crime at all times and ultimately the general theory of crime. They referenced back to the cause of low self-control describing the parenting that they claim is to blame and therefore theorized that bad parenting leads to low self-control that leads to crime, making low self-control the root of all crime. Gilbert Geis, a criminologist, has dissected the theory and found many deficiencies regarding its applicability to all crime. Although Geis admires the attempt to generalize a theory to explain all crime he also admires a saying that states â€Å"nothing is more tragic than the murder of a grand theory by a little fact† (p. 77). Through many examples of different crimes, criminal behaviors, and scenarios, Geis was able to dispute the self-control theory in regards to: its definition of crime, the matter of tautology, its discussion of criminal law, its inclusion of the acts analogous to crimes, exceptions to the theory, the role played in the theory by the concept of opportunity, its views about specialization in criminal behavior, its handling of the matter of aging, how it deals with white collar crime, research on the theory, ideological issues, and child-rearing and the theory. How much variance can the theory explain? There should be one theory per one type of crime. It is not likely that any contributing variable is applicable for all crimes. This is the idea that fueled Geis to dispute the claims made by Gottfredson and Hirschi. The idea of creating one general theory is too great of a goal where as a more modest and effective goal would be to create a family or group of theories to explain the root of most crime. It is believed by Geis that this self-control theory will be sloughed off as a general theory to explain all crime. Everything should be made as simple as possible but not simpler than possible. Research and facts that are incompatible with the theory should not have to be explained away or shaped to fit within the patterns consistent to the theory. A study conducted in 2007 by Cretacci examined self-controls ability to explain different forms of crime and whether the support that it has gained has been exaggerated. The results collected from these tests indicated that self-control theory is a predictor of probability of involvement in property and drug crime but is practically silent in its ability to explain crimes of violent nature. In addition to this, Cretacci also has found many logical deficits that exist in many explanations the theory is supposed to serve. One particular deficit is the idea of the stability of self-control. According to Gottfredson and Hirschi the level of self-control an individual possesses levels out around the age of 7 and remains the same throughout the individual’s lifetime. This information was only supported by one resource. Questioning this claim, Turner and Piquero conducted a study in 2002 to reexamine the resource utilized by Gottfredson and Hirschi that resulted in mixed support for their claim. Geis feels that the idea of explaining a massive field with one general theory is impossible. This belief applies to all human acts and broad categories such as criminal behavior. There are too many variables within a broad category or topic as such to be fully explained by one explanation. Human nature drives us to believe such easy explanations for sake of simplicity and solidity and this is often why individuals tend to hold theories such as this for truth even when factual research and support contradict said theory. A famous scientist once said â€Å"Nothing is more surprising than the way in which a theory will continue to survive long after its brains have been knocked out† (p. 177)

April ABC, Inc

In the beginning of April ABC, Inc. hired Carl Robins as their new campus recruiter. Carl was new to his position, but that did not stop him from striving to be a great recruiter right from the start. Carl successfully hired 15 new trainees to work for Monica Carrols the Operations Supervisor. Monica checked in with Carl to advise him of all the steps that are necessary to complete before the trainees could start working for the company. Carl felt confident about the situation and assured Monica that everything would be arranged in plenty of time. The goal is to have the trainees working by July; the problem is that Carl has neglected to make the proper arrangements to ensure all tasks will be accomplished. This analysis will try to come up with a good solution for Carl Robins to resolve the problems he has created. Carl has been in his recruiter position for six months; these 15 trainees are his first recruitment efforts for ABC, Inc. The trainees were recruited in early April; it was Carl’s hopes that he would have the hires working by July. The second week in May, Monica contacted Carl about the training schedule, letting him know it takes a lot of time to get the training schedule, policy booklets, manuals, drug test, physicals and many other areas scheduled. Carl would have to coordinate these tasks for the new employees before the new hire orientation; the orientation was dated for June 15. After Memorial Day, Carl looked over the new trainee files; the orientation was to take place in two weeks. As soon as Carl was done looking over the paperwork, he realized some of the trainees had not finished their applications, they did not have transcripts on file, and not one new hire had scheduled the mandatory drug screening. Many things Carl needed to be concerned about, he has been an employee for only six months, therefore if he does not fulfill this task, he might be in risk of loosing his job because this may not get another chance. He decided to look through the orientation manuals, but he had missing pages and he only had three copies; they would be no help in trying to prepare the materials for the orientation. Carl knew he confirmed Monica that everything would be done by the time for the new orientation course. Now he will have to figure out how he will execute the perfect plan to make things right again and have enough time to complete the tasks. Carl went to check the training room that he will use for the orientation training but he ound out that his co-worker Joe already reserved the room for giving computer training for the whole month of June. Carl did not know the training room was reserved and he will have to find a solution for finding a place to have the orientation; this was a major oversight from Carl’s part. Alternative solutions are needed in order to get Carl out of trouble and back on track and try not to loose his job. To start he can make a list of the pending tasks and give them an order of importance. He needs to have an estimate of time that will take each task and see how viable tasks are and if he needs an extra plan to make them happened. Carl can call a meeting with all the new hires and give them a list of requirements they will need to be considerate for a permanent position. Since the new hires will want the opportunity they will make the impossible to make it happen. The drug testing is mandatory and should be the top priority on his list; the second priority on the list, should be the manuals. Carl needs to complete the manuals; gather all the information and make sets of all the copies. If Carl can continue to be motivated to do a good job and make a great first impression, he can accomplish all tasks at hand. Once Carl has created his plan of action, he can make notes as to how he plans on figuring everything out. By contacting the new trainees that do not have a completed application and transcripts turned in he has not only informed the trainees of what is need from them in order to be completely hired, but he is also giving contact and that shows seriousness to the situation. If the new hires show up to orientation and do not have the drug screening complete they should be sent directly to the clinic to get the screening done. The reason the drug screening needs to be done prior to the orientation is the company does not want to hire anyone who is on drugs, so this task needs to be complete before they are even considered for the new hire orientation course. When the individuals show up for the course if they have not yet completed their part of the new orientation process they should be asked to leave; they can either complete their given tasks and contact Carl when they have done so or they can decided to not work for ABC, Inc.. The problem with allowing them to stay and complete the tasks at a later time is that they are getting a message that this is how they can conduct themselves while on the job. The manuals and incompatible reservations for the training room are Carl’s misdoings, so he needs to take responsibility for these matters. In order to have the orientation manuals be useful, Carl should consider completing the three that he has since they are only missing some pages and then make a power point slide show to use as the main course material. By turning the material into a power point slide he is giving the trainees a chance to take notes and he can create the presentation at home during off work hours. Carl should take one of the manuals and combine whatever information is missing into it. The situation with using the training rooms can only be fixed by Carl taking to his co-worker Joe. The new hire orientation only takes one day and since Joe has the room booked all month, he may not mind giving up one day, so his co-worker can utilize the space. If Joe says that Carl using the room is not possible, Carl needs to find another space to hold the orientation. The best thing to do would be to find another room that has access to a computer hook up and can display a power point presentation. There are only 15 new hires and they do not need computers for the course, so just about any space should do the job. Another solution could be for Carl to have the room for half a day on two different days; by doing this you give Joe his space everyday and he make be able to re-work his course schedule easier by not being asked to leave his room for a whole day. It is clear to see that Carl was slacking in all areas need to complete his first recruitment job for ABC, Inc. Carl did not plan ahead, he did not organize, and he did not prioritize any of the tasks. This being Carl’s first job for the company he should have taken it more seriously and he should have listened to the advice given to him by Monica Carrols, she is in a management position, has been with the company longer and knew what steps needed to be taken to succeed. Carl should learn from this mishap and always give himself plenty of time to complete a job the right way, he should listen to those who have valuable advice, and he should communicate with co-workers more effectively. If Carl can get his act together, he has real promise to being a great recruiter and asset for ABC, Inc.

Determine the Number of Moles for the Water of Crystallization in Copper Sulphate

Change in Potential Energy Worksheet 1. A 7. 3 kg gallon paint can is lifted 1. 78 meters vertically to a shelf. What is the change in potential energy of the paint can? 2. A roller coaster car of mass 465 kg rolls up a hill with a vertical height of 75 m from the ground. What is the change in potential energy relative to the ground? 3. If the car in problem #2 starts at rest from the height of 75 m, what will its speed be when it is 5 meters from the ground? What is the change in potential energy relative to the ground? What is the change in kinetic energy relative to the ground? 4.The same roller coaster car in problem #2 rolls down a vertical height of 40 m from the ground. What is the change in potential energy relative to the ground? 5. A 783 kg elevator rises straight up 164 meters. What is the change in potential energy of the elevator relative to the ground? 6. A car coasts 62. 2 meters along a hill that makes a 28. 3Â ° angle with the ground. If the car's mass is 1234 kg, t hen what is the change in potential energy? 7. a) How fast is the bicyclist traveling when she jumps off the ramp 4 m high? b) What is the maximum vertical height the bicyclist will reach? 8.What is the highest height Tarzan can travel to given the information above? 9. What is the jet’s new velocity if it coasts to its new, lower, altitude? 10. An 80 kg trucker loads a crate as shown below. He pushes the 40 kg box such that his arms are parallel to the ground. He pushes with a 100 N force. How much work is done by the trucker on the box? 11. A 2800 kg car exerts a constant force of 20,000 N while traveling across 50 m. The car starts from rest. (a) How much work is done by the car? (b) How much power is exerted by the car, in watts? 12. A car 2400 kg is traveling down the road at 26. 1 m/s.If the car accelerates up to 35 m/s over a distance of 200 m then (a) How much work is done by the car? (b) How much power is exerted by the car, in watts? 13. What is the work done over t he first 12 meters? What is the power if it is done in 1 minute? 14. What is the work done over the first 24 meters? What is the power if it is done in 1 hour? 15. What is the work done over the first 32 meters? What is the power if it is done in 30 minutes? 16. What is the work done over the first 52 meters? What is the power if it is done in 1200 s? 17. How much work is done between 32 and 52 meters? What was the change in power if it was

Customer value Essay Example | Topics and Well Written Essays - 2000 words

Customer value - Essay Example The main points discussed in the paper will be summed up in the conclusion. Samsung Electronics is based in South Korea and it specialises in manufacturing and distributing a wide range of consumer electronic products. The company was founded in 1938 and it has been involved in business of manufacturing electronic products for quite a long time. The company also has many affiliates as well as subsidiaries that operate under its brand name. According to the company’s 2012 annual report, Samsung is the world’s largest mobile phone manufacturer as indicated by the unit sales of the products. The smart phones offered by the company are by far the best compared to other products offered by rival competitors. Currently, the company operates in more than 200 countries across the globe and it has its own retail stores as well as subsidiaries that distribute its products to different customers across the whole world. Organizational objectives The main objective of Samsung Compan y is to offer products that are of superior value to the customers. The company is guided by a simple philosophy, â€Å"strong values and high ethical standards that inform our work every day. In everything we do, we strive to help people live better lives† (Samsung). ... The other objective of Samsung is to maintain market leadership and to increase market share through creating loyalty among the customers across the globe. The company also aims to invest in people as well as distribution systems with a long term view of building a strong customer base (Samsung). Product and brand portfolio Samsung offers a wide range of electronic products that include the following: IT and mobile communication technology, printers, televisions, radios, DVDs, CDs, health and medical equipment, washing machines, stoves, fridges, computers, home theatres, cameras, memory devices among other products. According to its Annual Report 2012, Samsung Electronics is the global leader in the mobile communication technology. Its Galaxy phone has given it a competitive advantage over other players in this field. The company has managed to attract millions of customers across the globe and it is also performing well in the area of televisions. Basically, the brand portfolio of S amsung Electronics is comprised of different state-of-the-art products that are valued by many customers. The brand name is very powerful and it is regarded as one of the best especially in mobile communication. Pricing strategies Attracting and retaining customers can be a difficult task given that they have a wide choice to make from the products offered in the market. In most cases, a customer buys from the firm that offers the highest customer perceived value especially on the basis of evaluating the difference between all benefits and costs of a market offering compared to those of competing products. The aspect of price of the product has a

Texas and The Death Penalty Research Paper Example | Topics and Well Written Essays - 1500 words

Texas and The Death Penalty - Research Paper Example Being represented by the right lawyer determines the chances of providing adequate evidence to ascertain one's innocence or guiltiness. Opponents of death penalties argue that some people may end up being killed while they are innocent if the trial is not fair or if the accused person’s counsel lacks expertise. This has raised the issue of the appropriateness of death execution for punishing offenders since the trial process may result in conviction and murder of innocent individuals (â€Å"American Civil Liberties Union† Web). Another issue surrounding the death penalty is diversity inconsistencies such as racial and gender. There have been arguments that the number of African Americans sentenced to death and executed is higher as compared to other races. Additionally, there are perceptions that cases where the victim is black rarely lead to death row while those involving white victims often lead to death rows. Such statistics have led to questions regarding the evenhandedness of the justice system when dealing with capital offenses. On the issue of diversity, there is a problem regarding the role of gender in determining the penalty. In most cases, capital offenses involving men are likely to lead to the death penalty as compared to those involving women. At times, this has created the notion that the justice system favors women suspects (â€Å"American Civil Liberties Union† Web). Another issue surrounding the death penalty in Texas is whether the punishment serves its purpose. Legal punishment is designed to correct the perpetrator of the crime and or deter others from committing such crimes.  

Gay and Lesbian Marriage Essay Example | Topics and Well Written Essays - 2000 words

Gay and Lesbian Marriage - Essay Example This is clearly a situation where, while actions are happening on the micro level of society, the response is being created by the macro level of society. Gidden's Theory of Structuration looks in detail at how all levels of society interact and help to create the responses of the other levels. Gidden's suggests that no social structure is permanent; rather it is built upon the actions of those who reside inside of it. While society can not be explained from the macro level, it can also not be explained without it. By reviewing the concept of gay/lesbian marriage from through Gidden's theory, a clearer view of society emerges. Gidden's argues that there is a duality to social structure. While it is created by those who live in it, they are also bound to follow its' rules (Fuchs 1). While it is clearly ever changing, there are also certain areas which remain static, based upon the culture that is being reviewed. Gay/lesbian marriage is an issue that is currently affecting all cultures, causing slow changes to the status quo. In European nations, gay marriage is slowly gaining in acceptance. However, it still meets with strong disapproval in the United States. A key difference between the two societies is the religious factor. While most European countries claim Christianity as their religion, there is also a certain lax feature about religion. It is accepted that a person may or may not be religious, and that therefore not all people should be bound by religious ideals. At the same time, the United States claims

Western Site Visit and Paper Essay Example | Topics and Well Written Essays - 1500 words

Western Site Visit and Paper - Essay Example My visit to this mosque was on a Friday. I prepared myself and arrived at about 11.00 a.m. Since I was new, I sorted to get some directions on what is required of me while in the mosque. So I went straight to the offices and I was welcomed warmly by the occupants who were in the office. Mr. Abdul, who introduced himself as a teacher for weekend Islam classes took the pleasure to show me around the mosque and to teach me the basic about Islam. Below is the conversation that followed between me and Mr. Abdul. Abdul: I am very pleased to have you here today. First and foremost, I will start with the basic things that you need to know about this religion. Islam is built on five pillars. The first one is Shahadah, where a believer expresses his commitment and acceptance of Islam. The shahadah is "There is no God but God and Muhammad is the Messenger of God." Abdul: And Prophet Muhammad is his Messenger. And you also go by the next pillars. The second pillar is prayer, commonly known as Salah in Islam. In prayer, a person communicates directly with God. A person is supposed to pray five times in a day and the prayers must be conducted while you are facing Mecca. Abdul: Because is the holiest city in Islam and also God instructed the Prophet Muhammad to pray while facing Qibla which is in Mecca. All Muslims in the world prays while facing Qibla. The third pillar is Zakat which means alms-giving or offering Muslims give to the needy. The fourth pillar is to fast during the holy month of  Ramadan, known as Sawm in Islam. The fifth pillar is visiting Mecca for pilgrimage. In Islam it is called Hajj. Abdul: Okay, the mosque or Masjid is the prayer house. It is a holy place and before entering, one must remove his or her shoes, clean him or herself with water. This act of cleaning is called tawadhah. The mosque is divided into two parts from

In instruction box Essay Example | Topics and Well Written Essays - 1000 words

In instruction box - Essay Example It is indeed not an uncommon phenomenon to encounter businesses marketing and selling their products online either through their own portals or by relying on sites owned and managed by third parties. In the first case, the company produces and markets the product online without necessarily relying on players in the traditional distribution channel such as distributors, wholesalers, and retailers. This paper will discuss how technological advancements and the Internet have impacted product distribution in the world today. The Case of Fujian Wanhua Electron and Technology Company Limited One company that relies on the Internet to distribute its products is the Fujian Wanhua Electron and Technology Company Limited. The company is based in China and was established in 1996 (Fujian Wanhua Electron & Technology Co. Ltd., 2013). The company produces a variety of electrical and electronic appliances for home, business, office, and corporate use. Some of the products that the company manufact ures and markets include car alarm systems, cordless telephone communication systems, network management systems, and home/office wireless burglar systems (Fujian Wanhua Electron & Technology Co. Ltd., 2013). ... Advantages of Direct Online Distribution of Products There are several advantages associated with direct distribution of products using the Internet. One main advantage with this method of distribution is its association with low overhead costs according to Time (2013). What this means is that the company is able to make a bigger profit that it would with the inclusion of intermediaries. This is the case considering that the company does not share the profits it gets with the intermediaries. Furthermore, a business that does direct online distribution is guaranteed to reach a global audience (Time, 2013). For example, although Fujian Wanhua Electron and Technology Company Limited is based in China, many people know about it or at least about its products across the globe. This may not be the case with businesses that rely on the traditional method of distribution. In many cases, they end up having a market that is limited in reach and therefore a smaller capital base. Yet another adv antage of direct distribution through the Internet is that it offers customers/consumers a lot of convenience (Time, 2013). Consumers can get to shop for the products they desire at any time of the day or night and at their convenience wherever they are as long as they have access to the Internet. What this means is that the consumers are not limited to shopping by time. Since intermediaries are not involved in the transactions, the customers benefit from the direct arrangement in that they get products at prices much cheaper than they would otherwise get with the involvement of intermediaries (Gillai & Lee, 2009). Many customers tend to like the idea of dealing directly with product producers (Time, 2013). Furthermore, the customers are more likely to receive superior customer care

Liberal Democratic Tradition Essay Example | Topics and Well Written Essays - 2000 words

Liberal Democratic Tradition - Essay Example From these principles, other elements of freedom include individualism, egalitarianism, universalism and meliorism. The presentation was positioned in the minds of the people that it gives a detailed point of liberation. Liberalism is being steered by certain themes such as not allowing the government to take control of people’s life (Buchanan 2008). A good number of Liberals believe that one is entitled to his/her opinions and thoughts. A rebel will agree with a woman who wants to abort. Liberals have support for every woman who is deemed free to choose what is good or bad for her. When it comes to love issues, most Liberals are not bothered with same-sex marriage. Liberals in America believe that every gay or straight is entitled to choose whom to love and marry. There is no boundary when it comes to the issues of the heart. It is clear for every liberal that everyone in society is free to believe in his or her religion. Individuals can believe in what their religion prescribes them to do (Mower, 2012). One can decide to worship throughout the week or even once per week depending on how they want it. If once decides to follow no religion its right for him/her. Religion should be kept private among individuals and that prayer should not interrupt other people (Barry 2009). Liberals believe that whether rich or poor everyone is subjected to equality. Economic conditions should not favor the privileged members of the society. Every member of the community is subjected to equal rights, Resources should be distributed amongst people equally without discrimination of age, race and gender. While individualism is a valid element egalitarianism, meliorism are primary fundamentals of liberalism. As promoted by classical liberalism, egalitarianism defines the equal opportunity everyone is entitled to. This will also comprise legal and political equality. Experts in the

How does faulkner portray the south book as i lay dying Essay

How does faulkner portray the south book as i lay dying - Essay Example In this novel, â€Å"William Faulkner portrays all of his themes in the actual human drama of the South† (Faulkner) the lack of communication, the poverty; ignorance and alienation are clearly engrained in the fabric of â€Å"As I Lay Dying.† Throughout the novel, the theme of lack of communication and alienations are the key factors for each and every character. The very nature of existing side by side with people is to communicate with each other for a better understanding. Lack of communication is one of the most common universal problems shown in As I Lay Dying. In the novel the characters methods of communicating with each other are many and vary. In most cases it depends on the characters relationships with one another. The characters do not communicate effectively with one another which lead to many confusion heartache and alienation. In the novel, the characters don’t always communicate with words, but they sometimes communicate through unspoken words. The communication between Dewey and Darl is often unspoken yet powerful. Yet part of Dewey Dell hates for this closeness: "And thats why I can talk to him with knowing with hating because he knows" (Faulkner 23). Darl feels that the words which he speaks, an d yet words, his words, can be seen as â€Å"†¦just a shape to fill a lack†¦Ã¢â‚¬  (Faulkner 172) with the lack of communications, the characters can only guess at the motivations, beliefs, and feelings of others. This results in misunderstandings and alienation with each other. As a result of this communication gap, the Bundren family lives an alienated life from each other. In his interview in 1959 Faulkner said about his character, "His tragedy is the impossibility-or at least the tremendous difficulty-of communication. But man keeps on trying endlessly to express himself and make contact with other human beings" (Faulkner). In the novel, Faulkner depicts the harsh reality of living in the south with empathy and grace but,

Recruiting plan for human resource Research Paper - 1

Recruiting plan for human resource - Research Paper Example ABC Ltd. is in expansion mode. The company has very recently set up a new zonal office in California. In order to backup the expansion strategy of the company additional manpower is required. Such circumstances have generated demand for manpower. Initially the company had the provision for one sales administrative assistant. But now the company has provision for one more sales administrative assistant. The office in CA has been opened very recently. Hence it would take round about one month or so make the plans and procedures operational. Therefore the recruitment is planned to be conducted for 20 days. The ten days have been kept as provision for certain contingencies that may occur. As far as training is concerned the company looking to recruit experienced candidates and hence on job training will be provided. The initial phase of the recruitment and selection procedure would be initiated by inviting application from the prospective applicants to create an applicant pool. This process would continue for one week. The sources of the applications are internal database, newspapers (print media), job portals, professional social networking sites and references. References made by the employees if gets converted successfully in the form of selection the employees making the references would be rewarded. Once the application bank is ready the HR department would conduct a screening. The screening would be conducted for three days. Based on the screening the shortlisted candidates would be interviewed telephonically. Candidates selected through the telephonic interview would be appearing for a face to face interview and excel test. The scores of the test and the face to face to face interview would be provided cumulatively. Recruitment is the process of drawing, screening and screening applicants. The stages of an ideal recruitment process involve analyzing the job, sourcing. The beginning point of the recruitment process is the job

Supporting Teaching and Learning Essay Example for Free

Supporting Teaching and Learning Essay Health and safety is monitored and maintained in various ways within School; we have Health and Safety policy that complies with the Health and Safety at work at 1974, this is available on the School’s VLE for all staff, parents and students to see, the Health and Safety policy outlines the main objectives, these objectives are implemented every day in school. All staff at School has regular training to keep them up to date with the current Health and Safety at school. Every department within School has a Health and Safety representative that is responsible for keeping individual departmental Health and Safety Policies up to date. Under the Health and Safety at work at 1974 all employees at Jack Hunt School has a responsibility to comply with Health and Safety within the School. All staff are to check equipment they are planning to use before the students use it, this is to ensure that it is safe. Staff in subjects where goggles, gloves or aprons are used they are to ensure that they not faulty and provided when required. Risk Assessments are an important part of protecting; staff, students and visitors to School. A risk assessment is carried out to identify potential risks and/or hazards, once you have identified the risk and/or hazard you would need to carry out a risk assessment to try to minimise the risk and/or hazard to a minimal and acceptable level for staff, pupils and visitors. When you are completing a risk assessment you need to remember that it is only effective at the time of assessment and should be monitored at all times reviewing if an accident should happen or annually whichever may arise first. You have a legal obligation to complete risk assessments for anything and everything you do at school whether this is onsite or offsite. Not only are risk assessments a legal requirement but if you do not complete risk assessments you are putting yourself, pupils, visitors and other staff in danger. Below is a flow chart on how to complete a risk assessment. Within School has overall responsibility for completing risk assessments. However, each department has their own risk assessments and the head of department or a nominated person within the department is responsible for completing the risk assessments and keeping them up to date. Learning support departments point of contact for risk assessments is R Reeves; she is responsible for all risk assessments that need carrying out with our department. Teachers are reasonable for completing their own risk assessments for their classroom and any classroom work that requires a risk assessment to be carried out. If there is a field trip going on it is down to the person in charge or whoever they may delegate to survey the location and complete risk assessments for any possible risks or hazards. All staff at School are made aware of any changes to risk assessments by either being verbally informed or by e-mail. If a new risk assessment has been generated staff will be made aware in the tri weekly staff meeting or by e-mail, all staff will be made aware of where the new risk assessment is located and how to access it. If the pupils require a risk assessment to participate in a science experiment or in design technology etc. they will be verbally told the risk assessment including the hazards, risks and what to do if an incident should arise. Visitors to school sign in and wear a visitors badge, by signing in they are saying they have read the main points within the health and safety policy, the main points are in the inside of the sign in folder.

Poetry on War An Analysis

Poetry on War An Analysis Opening with Auspices, an astonishing performance by Susan Mason which straightaway reminds of the African workers singing blues in 19th Century South American coltures, Poets on War clearly committed to the sufferings of war and imprisonment from the very beginning. Held on 1st February 2017 at the Southbank Centre, London, as part of The Poetry Librarys special edition, which takes place every first Wednesday of the month, the event was based on the participation of four contemporary poets, Ruth OCallaghan, Adnan al-Sayegh, Jenny Lewis and Hylda Sims, who tried to look at war with the sentiments of horror, sympathy and humour. As a result of a splendid collaboration between the diversity of such poets and their poems and the way they decided to lead them, the event immediately took the shades and the features of the so-called world literature, moving from London artistically and linguistically for a couple of hours. Ruth OCallaghan and some extracts from her collection Vortices (Shoestring, 2015) directed the first part of the evening. Approaching the idea of war and borders between countries and people, Ruth discusses and traces conflicts from bibical times to present day, raising the thought-provoking reflection that war has been an unfortunate constant in human beings lives and that poetry has followed it, giving voice to its effects and consequences. Hotel Owner is the poem that opens the first section and meditates on the idea of the hotel as a country without boundaries, in which people could feel safe, live and escape the world outside. 1914, on the other hand, treats the more technical part of the war, accounting for the ways in which slaughters have been perpetrated over history and particularly how death had different ideas in 1914. However, the most interesting points came out from Meine Liebe Mutter, which outlines the horrors of the war touching sensitively and respectfully the theme of son-mother relationship on the background of the Second World War. In concentration camps death had become ordinary and Ruth profoundly describes how the prisoners used to confront it: we never turned our face against the enemy, as killing is an intimate act. This striking idea of a connection between victim and murderer had a chilling impact on the whole audience: it placed a real difficulty in deciding with which part the reader would s ympathise. The relation established is so close but we are still so far from understanding the private, perpetual awareness of death. At last, before ending accompanied by a singing duet by Susan Mason and Emelia Lederleitnerova, Ruth quoted Tony Blair in his famous 1997 victory speech in which he claimed that his would have been the first generation ever not going to war or sending their children to war: as the poet observed after, he did not make the dream last long, declaring war on Talibans in 2001 and giving life to a new generation of soldiers and war poets. The second part of the event left space to the distinguished Iraqi poet-in-exile Adnan al-Sayegh. Experienced imprisonment during the Iran-Iraq war and sentenced to death in 1996 for the publication of the poem Uruks Anthem, Adnan took refuge in Sweden and has been living in London since 2004. His poetry, translated in several languages, is actively political and set against oppression and injustice, demonstrating an intense passion for freedom, love and beauty. In Poets on War, he gave the audience the pleasure to hear his lines recited in Arabic, their original language and then read out loud in translation thanks to the collaboration of Jenny Lewis, writer and teacher in poetry at Oxford University. Adnan transported the audience into another world: the melodic sound of Arabic was incredibly effective in trasmitting the sufferings and despair of the Iraqi experience and gave the event a touch of powerful originality. Delivering the message in the original language, the poet made clear how feelings such as pain and fear are universal and how languages and cultures become a way to make their acquaitance under different perspectives. Wars have broken out terribly equally everywhere and have made people escape their homelands in search of safer places, devastating lives and families: if nowhere is immune to war, then, as it was remarked in Second Song to Inanna/Ishtar, Let poetry be our country. The Iraqi poet actively shared the stage with two wonderful women: Jenny Lewis, who collaborated with him and participated with some poems of hers and Hylda Sims, who elegantly challenged all the skeptics who claim that war cannot be approached with any kind of humour. Gripping her guitar under her arm, she started singing her famous Bin Laden: Bin Ladens in my garden outside Canada Square!Shall I bring him a cup of tea?Im afraid hes got to go! Making the atmosphere lively and vibrant, Hylda gave a huge contribution to the structure of the event: she offered a new modern view on the theme of war by also incorporating the genre of the song and involved the audience in it teaching them her version of Adnans Sketch to sing, which made the small library look much more familiar. Besides being the elder component of the troop of Poets on War, her voice and tone proved to extremely grasp our times with consciousness, from the side of common people. Introducing her poem 21st Century War, which is very much about the 11th September 2001 terroristic attack, Hylda made a salient point about how war is still thriving around us but we are not always directly aware of it, even when we see its brutal consequences: as the events programme stated, The 21st century appears to already have equalled previous centuries for death, displacement, terrorism, political misjudgement and religious conflict and we as historical witnesses should keep a better pace with it. Overall, meant to be a travel in war poetry, this reunion of thoughts successfully caught the attention of the audience by mentioning contemporary and modern issues and by involving them in a friendly, accessible musical environment.

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