Interpersonal Communication Essay

In the healthiest of environments, people advance from ‘relationship’ to ‘engaged’ status because two people have mutually acknowledged each other, have common understandings, and act with the other person’s concerns in mind. A relationship, be it for marriage, friends or business, requires a domain of actions and an assessment that your partner is worth trust because they act with the intention to take care and not betray shared concerns. One of those elements is the interpersonal communication between the people in the relationship. When communicating effectively, there is a behavioral coordination that results from the coupling between two people in such a way that the relationship can limit the drift of day-to-day life, and move with effective communication practices that will address fundamental concerns. The bedrock of effective interpersonal communication is to first know who ‘you’ are. Review and understanding of your self-concept, self-image, self-esteem, and personality will allow for greater spaces for possibility to understand the same elements of your partner. Interpersonal communication involves both verbal and nonverbal communication and both of these communication types can be expressed in a variety of different ways. One aspect to clearly understand is that communication is complex because it involves two or more people to be in a dance of coordinated action that will take care of concerns and/or fulfill the narrative of the future. Communication is also continuous; to be most effective in the domain of interpersonal communication there is a requirement of recurrence, recursion  and reciprocation. Communication is also dynamic in that the action requires the embodiment of practices that allow you to transform between public, private and behavioral queues with your significant other. Equally important to remember is the misconception that communication cannot transform interpretation. Languaging is a linguistic coordination of linguistic coordination’s, a domain of descriptions of descriptions that refer back to themselves for meaning. Our classroom text asserts that we cannot exactly repeat something we have said in the past. Even if our words are the same – the tome of voice and other characteristics such as posturing and tone will differ- and the listener will also have a different impression (sole, K. 2011). Communication is also irreversible in that we cannot take back our words once spoken. This is why it is very important to be conscious of what you are saying in moments of anger when you might say something that you may later regret. The harmonious combination of two different points of view can certainly be viewed as a barrier to effective interpersonal communication because balance between the two is not always achieved. Common communication problems in relationships are assessed as: 1) Silence or refusal to speak; 2) giving into the other person at a cost of self or the relationship (also known as placating); and 3) psychological requests or reports – which is essentially the announcement of a feeling, emotion, or state of being without any commitment to act from the assessment produced an/or speaking without regard for the truth to fulfill a concealed agenda. Let’s face it – the silent treatment is more often than not a way of inflicting pain on the other person, or to get them as angry or disappointed as you are. Either way, there are no good outcomes possible for effectiveness to be achieved. Giving in to your significant others demands can defuse a negative situation, however, over the long term you can loose who your ‘self’ is and the foundation of the relationship can begin to become eroded. Visions of virtues, what is a good life, beliefs, and what is important for being taken care of can be lost subconsciously without you even knowing it when you give into placating. The last of the three barriers mentioned is psychological warfare. This could be sabotage born out of feelings of resignation, despair, boredom, resentment, distrust, confusion, being overwhelmed, and skepticism. It is important to try and be a third party observer of your moods because they color your outlook about your relationship and the world over extended periods of time. Moments of perturbation should be discussed with your partner in the moment or soon after so that bottled up aggression does not have the opportunity to morph into something much worse in the future such as ‘playing games’. As reviewed in chapter three of our classroom text, what you perceive in the world depends on what you pay attention to (Sole, K. 2011). With acceptance of this assertion then it is easier to understand how you organize and interpret what you perceive, and the framework of your emotions take place. Always remember that emotions are specific ungrounded assessments that live in our bodies for only a short period of time as feelings and thoughts. The perception of your partner may differ from your own; in fact, it most likely does because you both have had two different journeys throughout life from birth to the present moment. It is important to remember that emotions are the result of perturbations of our nervous system and provide automatic and ungrounded assessments about the world because as reviewed earlier, our individual ‘worlds’ are made up of only what we are paying attention to. Some emotions are inherited genetically and some are learned. Emotions though, only tell us how we ‘feel’; not the ‘truth’. With this in mind we can begin to understand then to be careful to know the difference between stating a ‘truth’ to our partner and making an ‘assertion’. With interpersonal relationships it is important to be aware of our emotions and how they affect the people around us, including our significant others. Non-verbal communication is defined as communication of a message without words, which means that it encompasses a wide range of vocal and visual signs and behaviors (Sole, K. 2011). Throughout your relationship you will  express yourself not only with your voice or with a pen, but also with eyes, facial expressions and body posturing. When listening to your significant other it is recommended to be aware of your body posture; the technical term for this is called kinesics. For example, sometimes there is no greater expression of affection for someone than the embrace of a hug or putting your arm around them (Burgoon, Buller, Woodall, 1996). As time goes on most partners begin to pick up on what the other is thinking without even speaking through non-verbal communication habits. For example, my fiancà ©e figured out that whenever I rub my eye with my index finger by putting pressure in corner of eye, I am in a mood of frustration or anger; and I never realized I did that till she pointed it out to me! Emotional Intelligence, also known as EI, is a reference to the capacity that someone has to understand, communicate, and manage emotions; and further the ability to understand and respond to the feelings of others (Sole, K. 2011). This is an especially powerful element to successful relationships because it expands the different possibilities for thinking and actions that a couple can take throughout a lifetime together. EI is a reference that someone has a background of listening taking place where future possibilities are being listened to, even while declarations for thinking or acting have taken, or are taking place. Take the various moods of yourself and your significant other for example. The understanding of moods can help in managing conflicts with one another. Moods color a persons point of view about life for periods of time and have body postures associated with it. If you see your significant other standing with their arms crossed and eyebrows bent while eyes are starring at you like daggers, then you may not need them to say that they are frustrated because you can interpret that with your level of emotional intelligence. A submission from my own meandering experience on like is to recognize the difference between the things you can, and the things you cannot change in life. Do your best to let go of negative thoughts and change negative interpretations. If your significant other is not able to spend a lot of time with you because of the amount of time you work for example, then  instead of ‘getting down’ on it be thankful that you get to end the day with him or her, and that they are ambitious instead of lazy. Another broad suggestion that does not encompass a specific situation would be to stay away from â€Å"I† statements. Our text for the class uses a great example for this. Instead of â€Å"you make me so angry sometimes† TRY: â€Å"I am so angry with you sometimes†. It shows that you are taking ownership for your own emotions and are describing a behavior instead of simply acting on it without thinking the situation through. CLOSING: The bedrock of effective interpersonal communication is to first know who ‘you’ are. Review and understanding of your self-concept, self-image, self-esteem, and personality will allow for greater spaces for possibility to understand the same elements of your partner. References Bower, B. (2010, November). Shared talking styles herald new and lasting romance. U.S. News & World Report, 1. Retrieved from ABI/INFORM Global on July 22, 2011. Document ID:2223940991 NARA SCHOENBERG. (2011, February 6). Can we talk? Researcher talks about the role of communication in marriages. Houston Chronicle,p. 7. Retrieved July 28, 2011, from ProQuest Newsstand. (Document ID: 2260839481). Nathan Miczo, Chris Segrin, & Lisa E Allspach. (2001). Relationship between nonverbal sensitivity, encoding, and relational satisfaction. Communication Reports, 14(1), 39-48. Retrieved July 25, 2011, from Research Library. (Document ID: 72022836). Preston, P. (2005). Nonverbal communication: Do you reallynsay what you mean? Journal of Healthcare Management, 50(2), 83-6. Retrieved from ABI/INFORM Global. Document ID: 814698921 Sole, K. (2011). Making connections: Understanding interpersonal communication. San Diego, CA: Bridgepoint Education, Inc. (https://content.ashford.edu)

Death Changes Everything Essay

As human beings live on, each experience takes a different effect. Some events can bring joy to a person’s life, but other events allow us to become grief-stricken. People have different ways to handle all the stressful situations that occur in their lives. Death challenges our ability to remain unchanged. No matter whom the person has lost, they become affected by their nonexistence. Through the life-changing event of death, many changes arise as a direct result of the loss. After losing a loved one or someone close, anger begins to boil inside. The death reminds us that we remain living. Some begin to wonder why they can not the replace the one who died. The person who changes the most experiences the transition from living life with someone to suffering the effects of the death. Anger forms inside and soon after depression follows. Throughout the entire experience of mourning a death, the feeling of loneliness and depression stalks every daily action, affecting the person negatively. Remaining isolated during such a difficult time affects the person’s mental health. Although the thoughts of having a quiet place seem comforting, that exact comfort can become something that negatively affects the way a person maneuvers all the changes that take place during the transition. A person’s mental health can reach a new low during the stage of depression, ultimately leading to the final stage. Acceptance could possibly revive a person’s outlook on life. After a person experiences the loss of someone close to them, the last challenge that a person must overcome may become recognized as acceptance. The realization a person embraces as a result to death acts as a great teacher. Life gains a new meaning and somehow motivates a person to live in a more satisfying life. Acceptance allows a person to display the positive effects of death. Each stage of grieving changes death and creates a less dramatic change for a person. Death can affect a person negatively or positively. A person experiences many steps while mourning their loss and each step assists them to eventually accept the fact that they have lost a close friend but their life still remains. Some stages of grieving effect a person differently. People control the way they respond to such a life-changing event. Throughout the grieving process many changes arise which affect a person as a direct result of death.

Environmental Security: Bangladesh Essay

Abstract While reading International Relations I got acquainted with many contemporary issues which are really important to deal with for the competitive survival of Bangladesh in this age of globalization. Bangladesh is a developing country. It has to perform very carefully in order to continue a healthy and sustainable economic system. Bangladesh suffers from both internal and external threats which are both military and non-military. Among them Environmental Security (ES) is a matter of great importance. Because environmental calamities are great threat to economic development and are means of creating dependency on the donor countries. It is also controlling relation between states and also creating tension between them. So, time has come to take this issue more significantly and take necessary steps accordingly. This research paper contains how environment is having power over the matters of our country; creating balance of relationship with the donor countries; and what Bangladesh shoul d do in order to overcome the problems to establish better economics. Acknowledgement In order to provide a valid research paper, I have taken information from the lecture shits given by the department of International Relations. Internet has been a great source of information which I have mentioned in the part of bibliography. Moreover I have taken information from BANGLADESH: Non-traditional security, By Jyoti M. Pathania, and used speeches of George Kennan, Collin Powell in some relevant area. I am grateful to Dr. Qazi Kholiquzzaman Ahmed (Chairman, Governing Council, Dhaka School of Economics (DScE); Chairman, Governing Body, Palli Karma-Sahayak Foundation). He has given me some clear view of the issue of Environmental Security. I have used some information in this research paper from his presentation on The Outcome OF Cancun Climate Change Conference (COP-16) and Bangladesh. My work has also been encouraged by Dr. jashim Uddin, General Manager, Palli Karma-Sahayak Foundation, who has great experience in the field of development in Bangladesh. 1.0 Introduction There have been two approaches to Security Studies: 1) Traditional Approach, i.e., Realist Approach and Non-traditional Approach, i.e., i) Widening Approach and ii) Deepening Approach. Since the end of the Cold War, there has been renewed interest in what is now called ‘non-traditional’ security issues. Among the non-traditional approach to security studies, the widening approach includes that states are functionally like units; states are not like units in terms of capability/power. Some are strong and some are weak. Inter-state relationship is governed by this power differentiation. As a result, anarchy is the ordering principle of international politics. States are bound to adapt to this anarchic system for their survival. However, in widening approach the referent object of security is state; state wants to secure state sovereignty, physical base of state (territory, resources and population) and political system. It simply includes a wide range of non-military threats to state security: both external and internal and military and non-military. The Environmental Security can be referred to this non-traditional approach of security, which is an internal and external non-military threat to a state that causes huge loss to the physical base of a state, demolishes economic situation and threats the sovereignty of state in this age of globalization. Hence the Environmental Security has become a matter of great importance in today’s world. Environmental security involves assessing the ways in which the quality of environmental systems relate to or impact the overall health and well-being of a state or society. It also refers to the relative protection of the environment from injury or degradation by manmade or natural processes due to accident, negligence, ignorance, or design from causes that cross national borders and endanger the livelihood or health of humans, the functional integrity of a state, or the stability of the international community. Most environmental threats to national and international security can be traced to man’s activities interfering into natural processes or the natural ecosystem. Some serious threats, however, may have natural origins, but become exacerbated from man’s activities. Examples of these include hurricanes, earthquakes and floods. Environmental Security (ES) is a matter of great importance since it also controls international relations between states. As late as 1985, the old cold warrior George Kennan Wrote in foreign affairs: Affairs concerning international relations and national interests in foreign countries. , identifying the threat to the world environment as one of the two supreme dangers facing mankind. But it was really in the post Cold War era that the world saw a dramatic increase in international activity around environmental issues. The United Nations Environmental Program has reported that about 170 treaties have been negotiated in recent years on various issues of the global environment. (1) 2.0 Importance of ES can be understood further by the following statement: â€Å"Few threats to peace and survival of the human community are greater than those posed by the prospects of cumulative and irreversible degradation of the biosphere on which human life depends. True security cannot be achieved by mounting buildup of weapons (defence in a narrow sense), but only by providing basic conditions for solving non-military problems which threatens them. Our survival depends not only on military balance, but on global cooperation to ensure a sustainable environment.† Brundtland Commission Report, 1987 In 1999, Collin Powell stressed the importance of ES saying: â€Å"Sustainable development is a compelling moral and humanitarian issue, but it is also a security imperative. Poverty, environmental degradation and despair are destroyers of people, of society, of nations. This unholy trinity can destabilize countries, even entire regions.† We are dependant upon the globe’s life-supporting eco-systems generating water, food, medicine, and clean air etc, but we actually did nothing to maintain this ecosystem. As a result the current and future generations will confront severe environmentally induced changes. The change has already started and is testing our traditional concepts and understandings of security, both national and beyond boundaries. In many cases conflicts are direct results of environmental degradation. Another important dimension of Environmental security is that it knows no state boundary. It affects humankind and its institutions and organizations anywhere and at anytime, which cannot be defended by any means of military defense or political negotiation. 3.0 VARIOUS INTERNATIONAL RELATIONS international relations, study of the relations among states and other political and economic units in the international system. Particular areas of study within the field of international relations include diplomacy and diplomatic history, international law, †¦.. Click the link for more information. THEORIES ON ENVIRONMENT A number of International Relations Theories can be applied to the issue of environment. Many of these theories only deal with the environment indirectly, yet it is useful to review the expanding literature of international-relations theory as it relates to the environment. Realism: The two central concepts of Realist theory are power and the national interest. The international society is an anarchical state-system. The system is therefore a self-help one. Realism assumes that states and their populations need natural resources to survive. There is a competition between states for these scarce resources. War is often the result of such competition and conflict. It leads to â€Å"the struggle for power and peace,† as Hans Morgenthau put it. (7) Extreme versions of Realism such as the geopolitical some see President George Bush’s intervention in Iraq as an attempt to secure the oil resources of the Middle East. 3.1 Malthusianism: Thomas Malthus, an 18th century English cleric, believed that because population grew in geometric progression and food production followed arithmetic progression, there would come a time when population growth would inevitably outstrip and will cause starvation. Thus it will threat the socio-economic security of a nation. 3.2 Liberalism: Liberalism focuses on cooperation. While liberalism sees people and states competing for scarce environmental resources, it does so in a more orderly way. Thus, â€Å"a liberal philosophy applied to global environmental politics tends to treat states as competitive participants–not unlike corporations–in markets they have established among themselves.† (8) Private enterprise and the market produce efficiency and save nature. For example, the Stockholm Declaration of 1972 forbids states from inflicting environmental damage on each other, because this would be a violation of the state’s sovereignty. 3.3 Institutionalism: This approach also focuses on cooperation. Here the states have a broader sense of self-interest. They focus on the public good. Their enlightened self-interest includes norms, values, principles and expectations which are the ingredients of International Regimes. The states seek mutually acceptable compromises through international negotiation. The building of International Regimes can benefit the global environment. The Kyoto Protocol of the UN Framework Convention on Climate Change is a good example of international regimes. 3.4 Ecoanarchism: This philosophy is humanistic and leftist, and Murray Bookchin is its leading proponent. Ecoanarchists believe that â€Å"the state and ‘big’ capital are inimical to the autonomy of humans and nature.† (9) Thus to preserve nature it is necessary to break society into â€Å"small, relatively self-sufficient units.† To help nature these units must practice altruism and mutual aid. 3.5 Social Naturalism: This view sees â€Å"culture and nature as bound together† in a kind of social community. Community is used in a very broad sense that includes people, animals, plants, ideas, language, history and the ecosystems. Cooperation between humans and nature is a given. The objective of social naturalism is â€Å"the creation of a cooperative ecological society found to be rooted in the most basic levels of being.† (10) This philosophy strongly resembles the worldview. 3.6 Sustainable Growth: The growth of incomes results in economic development. As the 1990s World Bank President Barber Conable put it: â€Å"market forces and economic efficiency were the best way to achieve the kind of growth which is the best antidote to poverty.† (12) So according to the neoclassical economist’s dictum â€Å"a rising tide lifts all boats† is associated with the idea that improvements in the general economy will benefit all participants in that economy. The proponents of this theory believe that when the poor of the developing countries become richer then it will reduce pressure on the environment. For example, they will be more able and willing to pay the costs of keeping air and water clean. (13) 3.7 Sustainable Development: This phrase first appeared in a 1980 report issued by the International Union for the Conservation of Nature International Union for the Conservation of Nature and Natural Resources (IUCN) or World Conservation Union, international organization founded in 1948 to encourage the preservation of wildlife, natural environments, and living resources. (14) This approach focuses on the â€Å"needs† of the world’s poor and calls for a sufficient transfer of wealth from the rich countries to the poor, so that the developing countries can deal with the problem of poverty and environmental damage. 3.8 The Steady-State Economy: Herman Daly proposed this alternative approach which focuses not on more goods, but on the durability and longevity of goods. More goods are wasteful and cause environmental degradation. It calls for recycling and the minimal exploitation of biological and physical resources. Daly’s unit is the nation-state, and each country must seek to be self-sufficient and spend only its own natural resources. (15) 3.9 Radical Redistribution: This theory believes that environmental degradation is the result of excessive wealth, the injustices of capitalism and the income inequality between the rich and the poor nations. In 2005, a typical American consumed 51 times as much energy as a typical Bangladeshi. (16) Consequently, two things need to be done. First, the rich must drastically reduce their consumption so as not to burden the earth’s resources and environment. Second, the rich much transfer massive amounts of capital and technology so that the poor countries can grow economically and preserve the environment. 3.10 Ecosocialism and Eco-Marxism: Not surprisingly, ecosocialists and ecomarxists blame capitalism for environmental degradation. Capitalism is seen as inherently anti-ecological and anti-nature. For seeking cheaper raw materials and fatter profits they impose wastes onto nature. Thus the mode of production matters for the environment. They â€Å"emphasize people’s collective power as producers, which directly involve local communities (particularly urban) and increase democracy, which enlist the labour movement and which are aimed particularly at economic life.† (17) 3.11 Ecofeminism: Although many ecofeminists are not Marxists, they are all leftists or liberal in their philosophical orientation. For ecofeminists â€Å"the domination of women and nature are inextricably linked.† (18) â€Å"Feminine suffering is universal because wrong done to women and its ongoing denial fuel the psycho-sexual abuse of all Others–races, children, animals, plants, rocks, water, and air.† (19) 3.12 Ecocentrism: Ecocentrists believe that humans cannot survive without nature. Many ecocentrists are advocates of wilderness or â€Å"wildness.† As Henry David Thoreau noted: â€Å"In wildness is the preservation of the world.† (20) 3.13 Biopolitics: The origins of biopolitics can be found in the writings of Michel Foucault. According to Mitchell Dean, a follower of Foucault, biopolitics â€Å"is concerned with matters of life and death, with birth and propagation, with health and illness, both physical and mental, and with the processes that sustain or retard the optimization of the life of a population.† (21) These are some of the basic environmental philosophies that take to mean the global environment and structure practices and policies. Many of these conflict with one another and have diverse explanation of the reasons for environmental degradation. 4.0 A case of Bangladesh: The first part of this research paper dealt with the security agenda and the philosophies involving ES. Scarcities of renewable resources can generate civil violence and conflict; the degradation of renewable resources causes environmental insufficiency; powerful groups take over precious resources while trivial groups move around to ecologically sensitive areas. Moreover environmental scarcity proves the difference between social groups. Such situation affects governmental institutions and states by making it economically weak. Even environmental scarcity can cause ethnic conflicts. Accordingly the International community can be indirectly affected by these conflicts produced by environmental scarcity. (22) In the second part I will focus on Bangladesh regarding the issues of environment security. Ours is a country which has to face both external and internal, and military and non military threats. Bangladesh achieved its independence through a devastating war against Pakistan which resulted millions of death and around ten million refugees to India. Even after the war Bangladesh has been facing military threat from the Shanti Bahini of Chittagong Hill Track (CHT). Guerrilla warfare between the rebels and armed force of the government in CHT and civil conflicts between the Bengali and Non-Bengali residents of this place continue till today. The most recent armed conflict between the Bengali and Non-Bengali residents happened on 19th January 2011; where 6 (six) were killed. Such situation threatens the stability of a state. Circumstances become more vulnerable when environmental degradation doubles the pain. The independent Bangladesh has been facing environmental calamity since 1974. In 1974 famine raged over and was further aggravated by a flood. Later on, the degradation only increased and in recent years Bangladesh has seen devastating cyclones and floods. The security of Bangladesh must depend on sustainable environment in many ways. Environmental degradation will badly affect economic development, erode social cohesion. Even political institutions face threat. Population growth and lack of economic opportunity will cause demographic displacement both within the country and outside. Migration in other country can cause bilateral conflict Bangladesh is also bearing the result of environmental problems of neighbor countries. Such situation in water sector is already exacerbating regional tension with India. It can lead to harmful progress towards regional security and can instigate regional cooperation on the other hand. We have to remember that the linkage of environment and security in Bangladesh is through economics and politics. The greater the environmental degradation in Bangladesh the greater will be the political and economic deterioration, thus leading to more national and international insecurity. 5.0 ENVIRONMENTAL CONCERNS IN BANGLADESH Bangladesh posses a horde of security problems, which are no longer of conventional nature but have non-conventional nature i.e. Non-traditional security issues which are in the state of constant evolution. These are economic, environmental, political and territorial threats. 5.1 Population The greatest problem that Bangladesh faces is an unusually large population in a small land area. The population grew from 42 million in 1951 to about 147 million in 2005. (23) It is projected to reach 166 million in 2015. (24) The population density is 1019 per square kilometer. When one compares this with 2 persons per sq. km. in Australia, 3 in Canada, 31 in USA, 191 in Pakistan and 324 in India, one becomes aware of the tremendous crush of population in Bangladesh. The faster the population increases, the more would be the negative effects on its environment. Zero population growth could serve for the environment in Bangladesh. 5.2 Land and Soil As noted earlier, Bangladesh covers a small area of only 144,000 square kilometers, but 63% of the total land is arable because it is located in the largest delta in the world. Formed by the three mighty rivers–the Ganges, Brahmaputra and the Meghna–it is also â€Å"the youngest and the most active delta in the world.† (27) Although Bangladesh is a flat alluvial plain, it does have complex soil condition and land pattern. Erosion of land by rivers is a serious problem in Bangladesh. Every year due to strong summer winds, powerful waves and shifting rivers thousands of acres of land are eroded away, leaving thousands of families homeless and contributing to the pattern of wholesale migration towards the urban areas, mainly to the capital city Dhaka. But it only creates instability in the society. 5.3 Deforestation Many decades ago Bangladesh had rich tropical forests. But due to population growth and the need for firewood and timber, the forests have become rapidly depleted. Currently the forest area comprises 13,000 square kilometers, about 10.2% of the total land space, which is much less than the universally accepted minimum of 25%. (28) Located in the southwest of Bangladesh, the Sundarbans is a mangrove, large tropical evergreen tree, genus Rhizophora that grows on muddy tidal flats and along protected ocean shorelines. It is the home for of the famous Royal Bengal Tiger as well as other rich flora and fauna. The United Nations has declared the Sundarbans as a world heritage site because of its rich biodiversity. Besides, the tropical rain forests in the Chittagong Hill Tracts, home to high value timber, rich vegetation and wild animals. Many animals are being rapidly depleted due to demand from both agriculture and industry. The Chokoria Sundarbans in the southeastern part of the country near the port-city Chittagong were completely destroyed in the 1980s and 1990s in order to facilitate shrimp farming. 5.4 Drought & Floods It is ironic that during the monsoon season Bangladesh has too much water and during the winter months too little water when no rainfall occurs. Thus the country is subject to both floods and drought. Barendra Bhumi of the northern part of our country is an example for drought affect. Because of drought people are unable to continue agricultural work and suffer from monga (unemployment). It also causes huge migration towards the capital city and other cities. Heavy drought also causes desertification in this area. On the other hand, in the rainy season Bangladesh suffers from too much water. About 1360 billion cubic meters of water is discharged annually through the GBM system, 93% of which flows through Bangladesh. If all the water did not flow into the sea, the country had been under 32 feet of water. The 230 rivers with their numerous creeks and rivulets attempt to drain the water into the Bay of Bengal But the situation of rivers, the low river gradients in the flat plain and strong backwater effects slow the passage to the sea, giving rise to the overflowing of the riverbanks. Every year there are floods, in some years it becomes extreme due to extra heavy rainfall. 5.5 Storms & Cyclones Bangladesh faces huge destruction due to storms and cyclones. The cyclones mainly hit the coastal region. Several severe cyclones emerge from the Bay of Bengal and the Indian Ocean. The funnel shape of the Bay increases the intensity, often blowing in excess of 240 km per hour and creating tidal bores 9 km high. One of the worst cyclones occurred on November 12, 1970, killing an estimated 300 hundred thousand people in addition to major damage to livestock, poultry, crops and vegetation. (30) The most recent examples can be SIDR (2007) and AILA (2009).

Business - Leadership and Change Essay Example | Topics and Well Written Essays - 1000 words

Business - Leadership and Change - Essay Example Hence, a viable leadership in a contemporary scenario comprises of a talent for fluidity and adaptability aimed at recognising the need for change and then the potential to lead change (Mullins 2004). Therefore, the capability to create, manage and lead change is of immense importance in the contemporary leaders. Such a versatile mode of leadership rests on a plethora of apt abilities like a viable vision, the power to inspire, effective communication, emotional intelligence and appropriate conflict resolution skills (Kotter et al. 2006). Effective leadership most of the times rests on a sound and solid vision (Zaccaro 2001, p. 106). However, the term ‘vision’ here does not mean a chunk of imaginary green cheese, which is conceptualised by a leader, sans any concern for the aspirations and opinions of one’s followers. In contrast, ‘vision’ comprises of a set of reasons, which could lead to a better future in an individual and organisational context an d which could be easily grasped and adhered to by personnel placed at all levels within a set up (Zaccaro 2001, p. 106). The hall mark of an effective leader is that one is capable of coming out with a vision with which each and every follower could identify with and commit to. It is only when individual followers see a personal stake in the collective vision that they go beyond their capabilities and stamina to make it a reality (Zaccaro 2001, p. 106). For instance, John F Kennedy came out with a vision to place a man on the moon (Barnes 2005, p. 154). The eventual success of this vision could be attributed to the fact that it extended something to aspire for and be proud about to every individual American (Barnes 2005, p. 154). Inspiration lies at the foundation of an effective leadership approach (Adair 2002, p. 110). Great leaders do always have the ability to inspire others to follow them. Yet, the biggest asset of an inspiring leader is that one is always willing to live the c hange that one intends to bring about (Adair 2002, p. 110). It is one’s passion to engage oneself in all the aspects of a change that one desires to bring about that makes the other followers reach the heights of performance (Storey 2004, p. 113). The leadership style of Gandhi was best known for his ability to inspire others through personal example (Adair 2002, p. 322). The one big thing about Gandhi was that he was always the first to adopt the change that he aspired to bring about in the society (Gandhi 2006). Such an approach most of the times succeeded in inspiring his followers to engage with his vision of change in a sincere and selfless manner (Gandhi 2006). A successful leader by necessity needs to be really good at communicating his vision (Kirkpatrick 2001, p. 47). However, as usually understood, communication is not merely about a drab exchange of prosaic ideas and information between a sender and the recipient. Communication is something much more than that. It is about the ability to exchange ideas and information with all the essential passion and emotions hovering around those ideas (Kirkpatrick 2001, p. 48). In leadership, communication is not merely about informing but also about moving, inspiring, motivating, energising, pacifying, and a range of other abilities, as and when required by a particular situation or challenge. Communication is about bringing in that essential human element in the exchange of information and ideas, which has the ability to wrest

Teaching all Standards Thesis Example | Topics and Well Written Essays - 9000 words - 1

Teaching all Standards - Thesis Example When developing a vision within a specific scholastic environment a large body of theoretical work and research indicates the importance of the school principle bringing together diverse viewpoints together under the auspices of a unified vision. In considering the means of accomplishing this task one of the first elements that must be developed is the nature and type of my own beliefs and motivations. In terms of establishing these beliefs I recognize that the important element is to think with the end in mind. In approaching the scholastic vision from this top-down constructivist approach it’s possible to establish the intended vision and then establish a variety of goals and avenues the scholastic environment can work towards achieving. The next step must be to consider the current scholastic environment and work towards developing a means of uniting these leaders and professionals in a cooperative and functional setting. In these regards, Fiore notes that, The relationship s among and between school stakeholders and how those relationships contribute to the overall purpose of schooling must be considered as the mission statement is crafted. Leaders are people who understand the interdependence of people. It is up to the leader, particularly in light of ISLLC Standard 1, to lead other toward the creation of a common purpose for schooling (Fiore, pg. 25) In these regards, the school environment becomes the primary area of focus, as the administrator must balance the end-goal with the current scholastic environment in order to establish and meet the desired vision. Indeed, I recognize that the nature of the current scholastic environment is an important consideration when establishing my overriding vision. Finally, it’s argued that after working towards uniting the professional community, the administrator must consider the â€Å"historical nature of the specific school† (Kowalski, pg. 209). This will be another major step taken in achievin g the scholastic vision. In terms of Kern County Elementary School one of the most pivotal aspects of developing a meaningful vision will be a thorough understanding of the school’s scholastic achievement levels. While this detailed information is not regularly available to the public, it is essential in developing a cohesive and proactive vision on a number of grounds. While community interaction and involvement are critical areas of school and student development, the scholastic environment is ultimately a place of academic learning. In these regards, upon assuming control of the school the first step that would be taken would be taking a large-scale overhaul of educational deficiencies, as well as areas of achievement. One of the realities of school administration is the understanding of county, city, and state standards. In large part funding and recognition are attached to the school’s successful adherence to these scholastic standards, as this allows for a cohesi ve educational community that can extend even to the national level. The next step will then be to develop a cohesive vision that will target these deficiencies and nurture these scholastic strengths. In accomplishing this goal a multi-tiered approach will be developed that targets all grade levels. Grade wide meetings will be called wherein the teachers of these specific grades will be informed of the areas of scholastic

Asset and Guest Security Essay Example | Topics and Well Written Essays - 750 words

Asset and Guest Security - Essay Example Since pieces of art have been collected from the world class artists, painters and museums, the protection and safety of these things requires comprehensive security schemes, so that the confidence and trust of the artists and guests in the gallery could be sustained. Alarm System: The main objective behind an art gallery is the displaying of worthwhile art pieces for the visitors and guests, so that the lovers of art could appreciate and evaluate the talented and exquisite work accomplished by the artists, painters and sculptors in an eloquent mode. Incorporation and inclusion of security alarm system is highly advisable for the protection of these precious assets of art. The alarm system should be adjusted in such a way that it could cover the entire edifice of art gallery from roof to the main entrance and from doors and windows to the all the four walls of the building. There should be no other entrance other than the main gate, monitoring of which should be double-checked by the security staff. The security staff must note the identity and entry time of every guest, so that in case of any doubt or loss, the visitors could be traced out easily. The security guards should be provided with metal detectors so that no person loaded with the weapo n could have entry in the gallery. The guards should be loaded with the latest weapons in order to face any untoward situation. Special Security on the Roof of Gallery: It has aptly been stated that in art exhibitions, the thieves use the roof of the building as the easiest way through which they can slip with the object of art quite easily. â€Å"The experience shows that fifty percent of all thefts take place on the upper floors of a building, or even from the roof. Security measures should not be limited to motion detection inside the building; if permitted by the surrounding environment, it is ideal to have a security system that

History Essay Example | Topics and Well Written Essays - 750 words - 21

History - Essay Example During the Middle Ages, Europeans had become keenly aware of the wealth existing outside of Europe, particularly in the Far East. Moreover, improvements in navigation and maritime technology during the 1400s meant that Europeans could access riches in other parts of the world with far more efficiency and effectiveness than ever before (McCannon 2008, 208). Spain and Portugal were the first European nations to venture across the Atlantic (Page and Sonneburg 2003, 481). Spanish reaction to the New World cultures across the Atlantic is characterized as mixed. Spanish ranchers, miners and farmers saw the Indians as a source of fre labor and set about attempting to and ultimately achieving these ambitions. Other Spaniards, particularly Spanish missionaries preferred to treat the New World Indian natives with a degree of compassion and to convert them to Christianity. Spanish bureaucrats were frequently at a crossroad, attempting to temper the call for compassion and conversion with the a desire to secure wealth by virtue of exploiting free labor (Benton 2002, 84). The Portuguese systematically took control of Asia building a commercial empire in the region. The Portuguese essentially established a monopoly over the Asian spices and other valuable products by seizing maritime control over Asian ports and acted as the sole trader between Asian nations and Europe (Love 2006, 27). Essentially, Spain and Portugal’s different treatment of their respective conquests were dictated by their respective discoveries. The Spanish encountered human capital rather than rich resources and therefore put their attention to reaping benefits in terms of free labor. The Portuguese encountered rich resources and focused their energies on taking control of those resources. In each case, the goal was to advance and improve economics and each conquering nation focused on how best to advance their economic positions by reference to the sources

What effect does the financial crisis have on the luxury fashion Essay - 1

What effect does the financial crisis have on the luxury fashion market - Essay Example Companies are looking forward to commence with some sort of strategies which would help them to retain their revenue and sustain in such economic turbulence. The predictions have been made that financial woes would continue for few years and will deflate consumer spending even more. (your statement) Â   The term financial crisis is largely used when the financial institutions lose a large quantity of their value. The financial crisis is allied with banking panics, stock market crashes, bursting of financial bubbles, currency crisis and sovereign defaults. The global financial calamity started in July 2007, when around the world stock markets collapsed, and the financial institutions plunged. The governments started to release some effective packages in order to save their financial systems. The investors became frightened by the abrupt decline in the stock market, which reduces their investments in the market. A luxury good is a good for which the demand of the consumer increases as the income level increases. Luxury goods have always been a symbol of prosperity and wealth for ages, for the spendthrifts, who desire and enjoy buying. Owning and wanting to be the owner of luxury items such as the latest designer clothes, jewelry, watches, is a pleasure on its own. Items that comes with a heavy price tag than ordinary items and have a known brand name is identified as luxury item. In economics, luxury goods have said to have high elasticity of demand, which means that when buyers become wealthier they would like to spend more and more cash on the luxury items. It also means that when there is a turn down in income level there will be a decrease in demand. Both income and demand are directly proportional to each other, if one increases the other rises as well and vice versa. Income elasticity of demand is not constant with respect to income, and the demand may changes at different income leve ls. That is to say, a

Death penalty Essay Example | Topics and Well Written Essays - 1000 words

Death penalty - Essay Example This paper will examine the benefits and the fall backs of the death penalty, and argue if it should be allowed or banned based on the evidence in the paper. According to Chan and Oxley, capital punishment is a legal process sanctioned by the state that allows for the termination of a felon offender’s life, who has committed one or multiple heinous offences (Janet and Oxley 2). This process is usually prohibited in many countries for the same questions that this paper raises and seeks to answer. Is capital punishment morally wrong? Does capital punishment deter crime? Can capital punishment be justified when done in consideration to the welfare of the public? Many people have found the death penalty or capital punishment to be morally wrong but when atrocities are committed against their loved ones, they quickly have a change of heart. Over the years, there has been a growing base of activists advocating for the abolishment of the death penalty all across the world, therefore, influencing many countries to abolish the act. Even the United Nations does not support the death penalty, citing a law borrowed from the American Bill of Rights, which stresses on the right to life. However, the United States of America has not given in to International pressure to abolish the death penalty but insists that the death penalty is neither cruel nor an unusual punishment when it is employed non-discriminatively and in an unarbitrary manner (Dezhbakhsh and Shepherd 512). Many individuals consider the death penalty to be morally impermissible. They argue that the act is constitutionally cruel and uncivilized. They claim that imposing capital punishment, no matter how humane the method of administration is, is still a transgression of the rule of law. They also say that capital punishment would lead to the wrongful death by execution to some innocent people whose cases were marred by false evidence. They argue that if the justice system was to make a mistake and realize it later after the death penalty has already been executed, the damage would be irreversible and unfair to the family and the individual. They also argue that capital punishment shows arbitrariness, in that the criminals may prefer that form of punishment. Capital punishment has also been said to be discriminative. Critics argue that racial discrimination is evident in the justice system, where criminals declared guilty of killing white people were four times more likely to be served with the death penalty than those who killed non-white individuals. This shows that the death penalty is discriminative even though it is said to be non-discriminatory (Sunstein and Vermeule 2). Capital punishment seems to have a few shortcomings but despite all that it can be regarded as an efficient tool to deter the occurrence of certain crimes. Research studies carried out two decades ago showed that the death penalty did not prevent or influence the occurrence of certain crimes. These research stud ies have refuted by new research that show that capital punishment has a powerful deterrent effect. The study proposes that for every execution carried out, an average of eighteen murders are prevented. With such an effect on crime, capital punishment should not be abolished as it seems to serve as a lesson to all those plotting some heinous crimes. Failing

Acceleration of falling cones Investigation Essay Example for Free

Acceleration of falling cones Investigation Essay Safety Statement:- To make this investigation safe I will wear sensible shoes, this make sure that I will not fall or trip on the table whilst carrying out the investigation. Prediction:- I predict that the smaller the surface area of the cone the faster it will fall. I know this as the more surface area the cone has the more air resistance there is. I also know this as when I carried out some research on parachutes, I discovered, that the larger the parachute the quicker the forces balanced, making the parachute fall slowly. Also, the smaller the parachute the longer it took for the forces to balance out, making the parachute fall much quicker. When I looked at a person freefalling (standing up) the results were that this also took at long time for the forces to balance out. When I saw the results of a person lying down I could see that the forced balanced out quickly, making the person fall slower. I know that it doesnt matter what weight an object has, it falls at the same acceleration, and lands on the ground at the same time. On the moon a feather and a golf ball were dropped at the same time, they both hit the surface of the moon at the same time. In any atmosphere when there is a gas or a liquid they initially drop at the same acceleration, encountering a drag force; this increases as it goes faster. The drag force increases until it equals the weight force, the forces are then balanced and it cant go any faster. This is called terminal velocity. Equipment:- The equipment that I shall use will be a stopwatch; to make sure that the times are as accurate as possible, a table of which to stand on when dropping the cone, and sensible shoes whilst standing on the table, I will also have a metre rule to measure the 2m distance, from the floor to the bottom of the cone. Method:- In this experiment I will time how long it takes for a cone to fall 2m. Each time I will make the cone slightly smaller, and therefore decreasing the surface area each time. I will then repeat each size three times: taking an average of the three times, of which I will then plot all the points on a graph. This will hopefully prove my prediction correct. The piece of card forming the cone will be moved 20? for each part of the experiment. Variables:- Distance, Surface area, Weight. The variable that I am going to change will be the surface area of the cone. This will help me determine whether or not my prediction is proven correct. Fair Test:- To make this experiment a fair test, I will take an average of the times of the cone falling after repeating the experiment three times. I will also make sure that I move the piece of card forming the cone around 20? each time, making the surface area of the cone decrease in regular intervals. Obtaining:- Results:- Angle (degrees? ) Surface Area (cm) Time (seconds) 1st Time (seconds) 2nd Time (seconds) 3rd Average Time (seconds) Velocity (m/s)nalysis:- My results show that the bigger the surface area of the cone the slower the cone would fall. This was due to the forces balancing out quicker. The smaller the surface area the quicker the cone would fall, it therefore takes longer for the forces to balance out, causing it to have a higher velocity. Looking at the graph above you can see that it did take longer for the cone to fall with a larger surface area. In the graph below you can see that the smaller the surface area the higher the velocity, (the time it took for the cone to fall in metres per second) My results show that my prediction was correct, the smaller the area the faster the cone will fall. The terminal velocity only lasted for a couple of cm, as the forces balanced out quite quickly. Velocity formula Distance = Velocity Time Example:- 2 = 1. 38 1. 45 The larger the area the smaller the velocity, this is because it takes longer for the cone to reach the ground. The larger the area the more air resistance it encounters, this makes it fall slower to the ground. My conclusion for this experiment is that the larger the area the longer it takes for the cone to fall, it therefore has a lower velocity. The smaller the area the quicker the cone falls, it also has a higher velocity. Evaluation:- The investigation I carried out was very good, as the results for each of the experiments that I carried out had almost the same time for each, the average was also very close to the time it took for each of the cones to fall. This data was very reliable. There are not any results that dont fit the pattern in the graphs. To carry out this investigation I had to measure the height of 2 metres of which the cone would be dropped each time. These results were then recorded, and then I took the average of each result, and plotted these points on a graph. If I did this experiment again I would take more results of each area to make the averages even more accurate, and reliable data. As well as having more data if this experiment was done again I would extend the experiment to involve weight. I would then try to prove that the weight of the cone would not affect the velocity and time of the cone falling. This would help me determine whether or not I was right about weight not being a factor of affecting the time and velocity. If I was to do this then this would be my experiment then this would be what I would do:- Prediction:- I predict that the weight would not make an impact on the time it takes for the cone to fall, and its velocity. Equipment:- Plastacine Stopwatch, Metre rule, Piece of card with cone and angles drawn on it. This time the variable I would change would be the weight of the cone. Method:- I would drop the cone with a ball of plastercine in it from a height of 2m. Each time I drop it I would change the weight of the plastercine, repeating this three times each for each different weight, this way I could get an average of the times, making it even more accurate. Acceleration and terminal velocity of falling cones.

The Boy in the Striped Pyjamas: Analysis

The Boy in the Striped Pyjamas: Analysis Thesis: When boundaries like social, cultural physical and separations constrained Bruno’s life, it never prevented him from forming a forbidden friendship Sana Ibrahim -3202 John Boyne is an Irish novelist born in Dublin. He wrote 70 short stories and many novels focused on adults and young readers. The Boy in Striped Pyjamas is a novel focused on a younger audience. Several film adaptations were done to this film and in 2006 film adaptation was an award-winning Miramax. Furthermore, the novel won 2 Irish awards and received positive reviews by many papers. For instance The Guardian reviewed as, â€Å"A small wonder of a book†¦this is what fiction is supposed to do† (Boyne, 2010-2014). The Boy in Striped Pyjamas is a fable which captures a hint of the holocaust but still has a great impact on our emotions. This is a story written from a 9 year old boy’s perspective, who lived during World War II. In this story the 9 year old Bruno along with his family moved from Berlin to Poland due to his father’s job promotion. His father was a Nazi officer who was recently appointed to the commander by the Fuhry. As a result they were sent to an isolated area near the â€Å"Out With† concentration camp. (In reality it is Auschwitz Concentration camp in Poland). In this story Bruno felt the loneliness of the place very much. This is because they were home schooled and he had no friends to play with unlike in Berlin. Bruno being a curious and adventurous explorer started to explore the house he lived paying no heed to boundaries. One day he sneaked from the back door and ran through the forest and ended finding a boy near a fence. He met the Jew boy Shmuel fo r the first time. They shared same birthday and age. Bruno sneaked every day to meet his friend near the fence as their budding relation prospered. One fateful day Bruno being a loyal friend to Shmuel decided to help find his dad trapped in the concentration camp. So he disguised in the striped pajama and crawled down the fence. Unfortunately, they ran into a death marching group leading to a gas chamber. They were naà ¯ve about what was about to happen as they walked into their death. It was their ill-fate that they were among the Jews who became the victims of the incinerators (Boyne, 2006). Despite the fact that Bruno was taught to hate the Jews as mortal enemies and his parents’ constant warnings, he proceeded with his virtues. When boundaries like social, cultural, and physical separations constrained the 9 year old boys’ life, it never prevented him from forming a forbidden friendship. Bruno’s family was portrayed as a rich family in Berlin as well as at Auschwitz. In Berlin they had a 5 story building in a position that entire city can be seen. Bruno says this in the story as he could see right across Berlin if he stood in his tiptoes as he held onto the window frame tightly. When they shifted to Poland they had a three story house with a rich life. There were servants attending to every need. However, in Bruno’s room through the only small window, he sees a farm like place from a distant. The area doesn’t look as lively as he thought it would be. His first impression was, â€Å"I don’t think other children look at all friendly,† (Boyne.p.18) even though his mother taught him not to prejudice others. Furthermore, Bruno is brought up in a place where he couldn’t interrupt his mother in any case. While they were about to leave the Berlin house, when the servant Maria interrupts, Bruno immediately recalls the rule of not inte rrupting his mother. Likewise, he cannot disturb his father unnecessarily. His father pays importance in maintaining disciple and the kids are forbidden to question their parents’ authority in decisions (Boyne, 2006). Judaism is considered as a religion by most scholars but the Germans describe Judaism as ethnicity (Hollingshead.p.4). During the holocaust due to this the two different groups were separated while the Jews behind a barbed fence deprived them from their lives. The Boy in Striped Pajamas reckons vast discrimination of Jews and Germans. For instance when Bruno and his family were travelling to Auschwitz they travelled by a train in which there were plenty of spaces for people to sit. On the one, Jews were tightly packed into the trains with undesirable conditions for a human being to breathe or live. â€Å"†¦transport arrived in Auschwitz on September 5, 1944 with 1,019 Jews on board. Men and women were separated† (United States of Holocaust Memorial, 2013). Jews were treated badly because they belonged to a certain ethnic group even though both groups were headed to same destination. During the time when Shmuel described how they came to the camp Bruno found it hard to bel ieve this since there was nothing like that in the trains they travelled. Moreover, having seen the documentary which shows the conditions and how the people were treated greatly influenced his little mind to believe things with in the camp were good (Boyne, 2006). As the two kids came to know each other more they ultimately believed each other more than the parents. This is the main reason why Bruno in the end with natural reluctance, joined his friend in the concentration camp. While the Nazis separated the two groups of people, they however failed to recognize their own type. This proves that what they actually hate is the religion not the people. While the Jews survived in misery, Germans had the choice to live. In this story Bruno was given all the freedom he wants within the household and beyond that he is deprived from this. For example the back door physically separated him from the surrounding. As he was not allowed to cross the door and the boredom pushed him to explore beyond it. Just like his tutor Herr Liszt encouraged in exploring, Bruno went pass the back door into the forest to discover new and interesting things just like the great explorers Christopher Columbus and Amerigo Vespucci (Boyne.p.56). On his first venture he found the boy sitting near the fence and their small talks resulted to build the trust in which each promised to be friends for life (Boyne, 2006). During World War II Jews and Christians were separated by the Germans providing bad conditions within the concentration camps. The Nazi officers removed their clothing and forced them to wear one â€Å"striped pajama† as in the story. In this story Bruno asks Shmuel why do they always wear pajamas and he responds that is the only type of clothing they get to wear unlike Bruno who wears different clothing every day. The Jews barely get to eat and almost every day when Bruno meets Shmuel he is hungry and longing for food. When Shmuel was brought to commanders house to clean the wine glasses Bruno offered Shmuel the fancy foods they eat which ended poor Jew being beaten by the officer (Boyne, 2006). During this time children were subjected to child labor and many were killed just as they arrived the camp. This is because the Officers believed that they are â€Å"useless eaters† (United States Holocaust Memorial, 2013), and immediately killed them in gas chambers.† On ly 6 to 11% of Europes prewar Jewish population of children survived† (United States Holocaust Memorial, 2013). Shmuel, Paul (who comes to peel vegetable) and other Jews in the camp are always sad, whereas the Germans are happy despite their brutality to humans. Bruno however worries and questions Shmuel about these although some answers are hard to believe because of the good conditions they have been subjected to in their lives. â€Å"Holocaust was an event of such consequence and philosophical significance it seems to transcend the boundaries of time† (Hollingshead, p.1).Through the eyes of Bruno the people inside the fence makes him sad. Although his sisters comment that they look â€Å"filthy† he rather says, â€Å"but maybe they don’t have any baths† than agreeing to the fact that they look dirty (Boyne, 2006). In a life where everything of Bruno is controlled by someone to a certain extent he manages to question certain behaviors and things even though he is not allowed to act differently in any circumstances. Bruno is a free spirit and at such a young age he considers his own thoughts over others. He finds his own ways to overcome the boredom at his new house. One day he makes a swing for him although he gets hurt at the end. He formed a strong bond with the dirty Jew boy he said at the beginning making him believe what is important in life is to accept people for who they are. References Boyne, J. (2010-2014) The Boy in the Striped Pyjamas http://www.johnboyne.com/fiction/younger-readers/the-boy-in-the-striped-pyjamas/ Boyne, J. (2006) The Boy in the Striped Pyjamas http://www.anderson5.net/cms/lib02/SC01001931/Centricity/Domain/222/The%20Boy%20in%20the%20Striped%20Pajamas.pdf Hollingshead, A. (2005-2006) G-d was not in Auschwitz http://www.gwu.edu/~uwp/fyw/euonymous/2005-2006/06-hollingsheadfinal.pdf United States Holocaust Memorial. (2013, 6) Plight of Jewish Children http://www.ushmm.org/wlc/en/article.php?ModuleId=10006124 United States Holocaust Memorial. (2013, 6) Children during the holocaust http://www.ushmm.org/wlc/en/article.php?ModuleId=10005142 Word count 1526

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