Explore How the Poet Creates the Scene in the Poem ‘in Romney Marsh’ free essay sample

Explore how the Poet Creates the Scene in the Poem ‘In Romney Marsh’. This poem centres on the experiences of the poet in the place Romney Marsh. Right from the beginning, we can tell that this is not going to be just an ordinary description of a place, because had it been that, the poet would have just named it ‘Romney Marsh’. The addition of the word ‘In’ makes the poem sound like an account of things that have happened there. This is backed up immediately by the first stanza, which begins with ‘As I went†¦Ã¢â‚¬â„¢ The fact that it is in the first person immediately sets the tone, and informs the reader that this is a personal story of the poet’s experiences with the Marsh. The anaphora of ‘I’ in the first stanza also helps to bring this out. Throughout the poem the poet makes frequent use of the senses. We will write a custom essay sample on Explore How the Poet Creates the Scene in the Poem ‘in Romney Marsh’ or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Sounds are very prominent in this poem, as they bring the place to life. For example, ‘ringing shrilly’, or ‘clashed on the shore’. In the former example, at the start of the second stanza, this phrase is significant, as it effectively kills the jovial, relaxed mood from the first stanza, and creates a rather more eerie one. This mood does not last long however, and with the phrase ‘a veil of purple vapour flowed’, the jovial mood is restored. This image is one of several, along with ‘like sapphire glowed’, and ‘the saffron beach, all diamond drops’, which contain royal and rich connotations, emphasising how special this place is for the poet, that he would go as far as to compare it to expensive, valuable things like diamonds or saffron. The tranquil mood is upheld throughout by words of gentle movement such as ‘flowed’, ‘trailed’, or ‘wagged’. These all bring the place to life and give it a peaceful, tranquil atmosphere. There are several examples throughout the poem of religious imagery, whereby the poet compares something in the marsh to something sacred or deeply religious. For example, ‘roses filled Heaven’s central gates’. Here he has possibly arrived at Dymchurch wall and could be comparing a gate there to a gate in Heaven, which again emphasises how this marsh is effectively like heaven for the poet. The poet uses several metaphors and similes to bring out his admiration for the marsh. When night falls, he compares the stars that come out to ‘flakes of silver fire’, which presents a rather romantic image of the marsh. In the fourth stanza he continues his trend of comparing the marsh to rich and royal things, by saying ‘beads of surge’. Here he is really describing the white of the waves, and comparing it to pearls. There s also plenty of personification, most notably in the first stanza, where he writes ‘I heard the South sing o’er the land’, referring to the south wind, and personifying it to bring the place to life. Alliteration also plays a key role in this poem, especially in the first stanza, where there is alliteration in every line. For instance, ‘down to Dymchurch’, or ‘knolls where Norman†¦Ã¢â‚¬â„¢ This alliteration adds to the rhythmic, musical feeling to create a peaceful, positive atmosphere at the start of the poem. There is also sibilance used to imitate the sound of the wind, in ‘South sing’. In the phrase ‘flicker and fade from out the west’, the poet uses alliteration to bring out the movement of fire, comparing the sunset to bits of fire falling from the sky. This poem is written in iambic tetrameter, which gives a rhythmic feeling to the poem, and it might imitate the rhythm of the poet’s footsteps on his journey through the marsh. The regular alternate rhyme scheme reflects the harmony between all of the elements of Romney Marsh. The structure is seven regular stanzas, and it parallels his journey through the marsh. From the fifth stanza onwards, he has turned around and is heading back. He writes similar phrases to the early stanzas, but simply inverts them. For example, ‘as I went down to Dymchurch Wall’, becomes ‘as I came up from Dymchurch Wall’. In the penultimate stanza, there is a caesura in the first line, which breaks up the rhythm and creates a pause to mark the big moment of ‘Night sank:’ This blunt statement indicates that he might be sad that he can’t see his lovely marsh any longer, but his sadness then disappears as he describes the beautiful night sky.

Immigrants in America

Immigrants in America Introduction People from different countries move to settle in the United States for various reasons such as seeking a peaceful life, job opportunities, and quality education.Advertising We will write a custom research paper sample on Immigrants in America specifically for you for only $16.05 $11/page Learn More The successful incorporation of immigrants into the American society has always hinged on the potential for personal improvement through educational and economic achievement (Immigration in America Today: An Encyclopedia, Loucky et al.). Due to the complex process that legal immigrants have to go through to gain entry into the United States, most immigrants gain entry through illegal means. For a very long time, immigration has led to so much tension in countries that have ended up receiving the immigrants. Ordinarily, immigrants are hailed by governments and business tycoons for economic reasons. However, the unity of a nation can easily be interfer ed with when the number of foreigners is too high. Over the years, nations have been inviting business minded individuals from places such as China, Israel, and Germany in order to strengthen their economies. Recently, my family and I moved to settle in the United States in search of better education and a better life. To fit into the American community, we are all doing our best to learn the American way of life. Among others, this includes going to school and learning the English language. This paper looks at three myths regarding immigration in the United States. First, there is the concern that immigrants are never willing to learn English. Secondly, immigrants are blamed for taking jobs and opportunity away from Americans. Third, immigrants are regarded as a drain on the American economy (Top 10 Immigration Myths and Facts, NIF). Arguments on Immigrants not willing to Learn English According to NIF many immigrants work hard to learn the English language immediately they step in to the United States and within a short time, they are usually able to speak the language quite well. This claim may be supported by the fact that demand for adult English classes always creates a desperate need for institutions and teachers to handle teach the students. Looking at my personal experience, I am strongly convinced that this claim may not necessarily be true. When my family and I moved to the United States, it was all because we desired a better life and great job opportunities. To be fully integrated into the American community, my parents and I have to keep on learning the English language. Personally, I had to take a part time job while undergoing my studies at the university. In support of my ambitions, my parents set up a home studio as soon as they acquired a family house.Advertising Looking for research paper on social sciences? Let's see if we can help you! Get your first paper with 15% OFF Learn More Arguments on Immigrants taking Jobs and Opportunities away from Americans The common myth here is that foreigners who enter and settle in the United States of America end up taking jobs and opportunities that are, allegedly, meant for the native-born Americans. However, studies indicate that immigrants greatly contributed to the growth of the American economy at a time when the nation was experiencing the lowest unemployment rate. As observed by the National Immigration Forum (NIF): â€Å"The largest wave of immigration to the U.S. since the early 1900s coincided with the country’s lowest national unemployment rate and fastest economic growth.† (Top 10 Immigration Myths and Facts, NIF). Clearly, the growth in the economy can easily be attributed to the increased number of immigrants into the United States. Immigrant business men and women contributed to the American economy by creating jobs for both Americans and foreign workers during this period. According to NIF, immigrant owned business can be found in places like the Silicon Valley, owned by Chinese and Indian immigrants. Apparently, these businesses managed to net over US$ 19.5 billion in sales besides creating close to 73,000 employment opportunities in the year 2000 (Top 10 Immigration Myths and Facts, NIF). The open door policy in effect until the 1920s had positive consequences for many. This is contrary to thinking of some natives that immigrants would take away their job (Keeping the Borders Open Does Not Harm U.S. Workers, Oppenheimer). During this period, much of the nation, particularly its industrial cities, greatly benefited from large scale entry by immigrants, whether legal or illegal. As immigrants took bottom level jobs, employment opportunities for skilled native residents increased tremendously. The cities of the Northeast and Midwest that became world class industrial centers during the nineteenth century owed much of their growth to these immigrants. In the decades following World War I, European immigrants comprised about a quarter of the workforce in America’s burgeoning industrial centers. Two cities, Chicago and New York, exemplified the contribution of immigrant workers who in 1920s, comprised about half their labor force. Both reached their highpoint of wealth and power during this decade. However, not everyone benefited. In the rural areas of South and Midwest, where few immigrants settled, economic gains were negligible. I cities where immigrants did congregate, benefits among the native born accrued largely to property owners, members of the middle class, and skilled workers. Unskilled workers, especially blacks gained very little. As a matter of fact, the flow of immigrants probably dampened the economic progress of blacks by slowing their exodus from the South. As the average income of American workers rose, the gap between the rich and the poor widened, fueling antagonism toward immigrants among citizens who were less well off.Advertising We will write a cus tom research paper sample on Immigrants in America specifically for you for only $16.05 $11/page Learn More When, beginning in the 1920s, restrictions were imposed on immigration the impact was greatest in those cities with large immigrant populations (Employment Verification Will Deter Illegal Immigration, Rector). Natives who migrated to cities once immigrant flow ceased appear to have contributed less to urban development than did the foreign born population. Most probably, the decline of America’s large industrial cities, beginning immediately after World War II may as well be linked to the change in immigration policy (The New Americans: A Guide to Immigration since 1965, Waters et al.). The latest immigration surge, which began in the 1960s, has facilitated urban renewal by strengthening small businesses, providing low wage labor, and maintaining the population base necessary to sustain a high level of economic activity. Seemingly, the new immigrants w ho include unskilled workers, professionals, and entrepreneurs have encouraged the flow of investment, furnished workers for factories and service industries, and helped revive deteriorating urban neighborhoods (Employment Verification Will Not Deter Illegal Immigration, DeWeese). This has been especially true in cities serving as gateways to other continents such as Los Angeles, New York, Miami, and San Francisco which, since the mid 1970s, have sprouted new offices, added jobs, particularly I the service industries, reduced unemployment, and shown other sign of urban renewal. Apparently, these cities have the highest concentration of new immigrants in the United States. The most striking evidence of urban transformation has been the changing racial composition of major cities. In the 1920s, 95 per cent of the residents of dozen largest cities were of European descent. Today, non Hispanic whites have become a minority in most of those cities. It is quite obvious that additional imm igration into the United States will only hasten these changes. Arguments on Immigrants being regarded as a Drain on the American Economy Despite claims that immigrants generally drain the American economy, studies prove otherwise. As argued by NIF, most new workers in the United States during the 1990s were foreigners. Notably, immigrants occupied various positions left by native-born Americans (Top 10 Immigration Myths and Facts, NIF).Advertising Looking for research paper on social sciences? Let's see if we can help you! Get your first paper with 15% OFF Learn More Studies by the National Academy of Sciences, Center for Labor Market Studies at Northeastern University, and Federal Reserves indicated that jobs in critical economic sectors in the United States were taken up by foreign nationals. Immigrants also work hard to start their own businesses and as a result, they contribute tremendously to America’s economic growth. Statistics also indicate that total benefit associated with immigration to America is a net of close to US$10 billion per year. In addition, most people who move to settle in the United States are working age. These are people who have already earned their education and are ready to use the skills they have acquired over the years to serve in different sectors of the US economy (Top 10 Immigration Myths and Facts, NIF). This argument clearly points to the fact that immigrants are not in any way a drain to the US economy. Instead, they are the very people who have contributed to what the American economy is today. It is also important to note that throughout the American history, immigration has been favored by American presidents interested with seeking economic expansion for their country (Immigrants and the U.S. Labor Market, Marcelli). These presidents were totally convinced that immigrants are a blessing to the American economy and as such, they should be invited in. Sadly, however, these presidents often met with great opposition coming from native-born Americans opposed to the idea of letting immigrants flow into the country. Despite the popular discontent that the presence of immigrants often provoked, leaders in the United States as well as other Western countries have acted in a manner likely to suggest that they are not ready to let their countries lose economic gains associated with immigration. Since the first Congress debated the issue of immigrants, immigration policy in the United States has been bound up with some very basic concerns which include economic well being, national ide ntity, internal stability, and the American role in the world. Over the years, public opinion on immigration has been marked by uncertainty. While some people see immigrants as productive workers who can be absorbed into the national mainstream without much disruption, others tend to take a much narrower view, regarding immigrants primarily as economic competitors or as foreigners with alien values. Most American presidents, viewing immigration from a national perspective, attach considerable political and economic importance to the large urban centers in which immigrants concentrate (Preface to Does Illegal Immigration Harm US Citizens?, Hanson). Although television has particularly become a major shaper of opinion, the images shown on the screen generally send conflicting messages. On one hand, immigrants are favorably portrayed as hardworking exemplars of the American dream. Whenever legislators consider revising immigration laws, dire predictions are issued regarding the economi c and social consequences of accepting more aliens. Apparently, these forecasts often turn out to be wrong. For example, two generations ago, restrictions were placed on the influx of Eastern and Southern European immigrants on the grounds that they were undesirable. Today, the nation proudly trumpets the achievements of these same groups. Indeed, Americans who favor continued immigration point reassuringly to the contributions of immigrants and their children as evidence of the nation’s ability to assimilate more aliens. Some people, however, view, with so much uneasiness, the growing number of immigrants, most of them from under developed nations. They fear that America will not be able to cope, economically or socially, with the multitudes of the poor and hungry people eager to cross borders into the United States of America. With the global population doubling every forty years, they see no end to the torrent of immigrants into their country. Seemingly, this fear extends to the countless refugees who flee their home lands when political repression becomes intolerable. Interestingly, however, fewer people express concern that the number of legal entrants is also growing primarily as a result of family reunification. In suburban areas across the nation, antigrowth sentiments are witnessed all over. Congestion has replaced the weather as a major topic of casual conversation. Complaints about traffic proliferate, but, like the weather, it seems beyond control. The nation seeks economic growth to satisfy material wants yet appears unwilling to deal with its adverse consequences such as too many cars and too few places to dump trash (Why Immigrants Come to America: Braceros, Indocumentados, and the Migra, Stout). In addition to these, national organizations are formed to support zero growth policies. In spite of the fact there is quite a huge population in the United States which is strongly opposed to the idea of welcoming immigrants into the country, im migrant business men and women are doing so much to help fuel the American economy through job creations and taking on jobs considered unacceptable by the native-born Americans (Immigrants: the Unsung Heroes of the U.S. Economy, Rayasam). Conclusion Notwithstanding the contributions of immigrants, American Central cities continue to face serious economic disruptions and social problems. The abandonment of massive public housing projects, many built on the foundations of tenements that housed earlier immigrants, stands as a constant reminder of the failed urban social policies. Over the years, violent crime has been on the rise, drug abuse continues to take its deadly toll of the young, and neighborhoods that house the underclass remain plagued by unemployment, poverty, and despair. Residents of formerly safe neighborhoods now fear to leave their homes. Restricting the flow of young immigrants could exact an economic price. America’s native population is aging, increasing the ration of non workers to workers. Also, as the base of the economy continues to shift from manufacturing to services, productivity gains in the coming years are expected to be modest. Unless there is an inflow of new labor, particularly skilled workers, the living standards in the United States could drop drastically. A report of the National Commission for Employment Policy suggests that, in order to meet projected labor demands, the nation may need to strongly encourage immigration. However, it seems unlikely that any such encouragement will be necessary since the United States still remains as attractive as ever to would be immigrants. References DeWeese, T. (2009). Employment Verification Will Not Deter Illegal Immigration. Retrieved from http://ic.galegroup.com/ic/ovic/ViewpointsDetailsPage/ViewpointsDetailsWindow?failOverType=query=prodId=OVICwindowstate=normalcontentModules=mode=viewdisplayGroupName=Viewpointslimiter=currPage=disableHighlighting=falsesource=sortBy=displayGrou ps=search_within_results=action=ecatId=activityType=scanId=documentId=GALE%7CEJ3010227278 Hanson, G. H. (2012). Preface to Does Illegal Immigration Harm US Citizens? Retrieved from http://ic.galegroup.com/ic/ovic/ViewpointsDetailsPage/ViewpointsDetailsWindow?failOverType=query=prodId=OVICwindowstate=normalcontentModules=mode=viewdisplayGroupName=Viewpointslimiter=currPage=disableHighlighting=falsesource=sortBy=displayGroups=search_within_results=action=ecatId=activityType=scanId=documentId=GALE%7CEJ3010499137 Loucky, J., Armstrong, J., Estrada, L. J. (2006). Immigration in America Today: An Encyclopedia. Westport, CT: Greenwood Publishing Group. National Immigration Forum (NIF). (2003). Top 10 Immigration Myths and Facts. Retrieved from immigrationforum.org/images/uploads/MythsandFacts.pdf Oppenheimer, M. (2010). Keeping the Borders Open Does Not Harm U.S. Workers. Retrieved from http://ic.galegroup.com/ic/ovic/ViewpointsDetailsPage/ViewpointsDetailsWindow?failOverType=query=prodId =OVICwindowstate=normalcontentModules=mode=viewdisplayGroupName=Viewpointslimiter=currPage=disableHighlighting=falsesource=sortBy=displayGroups=search_within_results=action=ecatId=activityType=scanId=documentId=GALE%7CEJ3010615206 Rector, R. (2009). Employment Verification Will Deter Illegal Immigration. Retrieved from http://ic.galegroup.com/ic/ovic/ViewpointsDetailsPage/ViewpointsDetailsWindow?failOverType=query=prodId=OVICwindowstate=normalcontentModules=mode=viewdisplayGroupName=Viewpointslimiter=currPage=disableHighlighting=falsesource=sortBy=displayGroups=search_within_results=action=ecatId=activityType=scanId=documentId=GALE%7CEJ3010227277 Stout, R. J. (2008). Why Immigrants Come to America: Braceros, Indocumentados, and the Migra. Westport, CT: Greenwood Publishing Group. Waters, M. C., Ueda, R., Marrow, H. B. (2007). The New Americans: A Guide to Immigration since 1965. Harvard Yard Cambridge, MA: Harvard University Press. Rayasam, R. (2007). Immigrants: the Unsung Heroes o f the U.S. Economy. U.S. News World Report, 00415537, 2/26/2007, Vol. 142, Issue 7. Retrieved from http://web.ebscohost.com/ehost/detail?sid=ebbab819-0e32-4438-9725-601871cd7d49%40sessionmgr12vid=10hid=12bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aphAN=24165745 Marcelli, E. (2005). Immigrants and the U.S. Labor Market. NACLA Report on the Americas, 10714839, Mar/Apr2005, Vol. 38, Issue 5. Retrieved from http://web.ebscohost.com/ehost/detail?sid=ebbab819-0e32-4438-9725-601871cd7d49%40sessionmgr12vid=12hid=12bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aphAN=16261289

Compare and Contrast Huckleberry Finn to Douglas's Search for Essay

Compare and Contrast Huckleberry Finn to Douglas's Search for Happiness and Freedom - Essay Example Douglas is a slave who inherited his slave status from his mother. Since his childhood, he has lived and behaved, as their masters require to slaves. His story is well told in his narrative until his success story when he manages on escaping. His story has similarities and differences when compared with the story of Huckleberry Finn. Both Finn and Douglas have grown up without the knowledge of their fathers. In their writing, they prove to have spent all their lives trying to figure out the person who could be their father. Douglas could have asked his mother, but she died when he was a child. No one was left with the information he needed to know, and if the father was alive, he did not want to be identified. According to the statements given in his narrative, the master of his mother was his father. However, the master could not declare or raise his voice to confirm his doubts since he wanted to have the privilege of being both a master and a father. It is clear that Douglas has ne ver been able to get information regarding his father. On the other hand, Finn has a father but has been lost for sometime as par the novel. He was a drunkard who would lie down with the hogs once he had too much to drink. This can be identified as contrast between these two writers. However, there is some aspect of similarity since Finn is rejected. Both of them have to undergo difficulties in life because they lack parents. Finn cannot be involved in his group because he could not keep to the requirements of the oath. The oath stated that if any boy told their secrets the punishment would be killing of their families. Finn lacked a family hence the reason for neglection. This gives a reason for the boys to rule him out since he lacked someone they would kill. They claimed that it would be unfair if he were included in the oath taking (Twain 34). Similarly, Douglas had many difficulties just because he lacked a family. His mother dies when he is extremely young and is forced to fac e life on his own. It would be possible to state that he had an aunt who would take care o him. The fact is that, she was always busy in the farm to the extent that she cold not takes great care of Douglas as young boy. This leads to the start of Douglas as slave at a very young age. As Fin is in his search for happiness, he indulges in many unlawful activities. He is signed in as a party in a gang of robbers who seem to have ability to kill (Twain 57). In their quest for freedom, they meet women who are ready to assist them. Christianity is portrayed as a way of achieving freedom among people who are oppressed. Douglas is capable of using Christian literatures to learn how to read. His master is very unhappy when he realizes that his wife is teaching a lave religion. He is furious because he believes that religion knowledge given to a slave brings them entitlement to end their time as slaves. This could be true because Douglas acquired freedom through the knowledge of religion. Fin n has a good woman taking care of him. She always reminds him to pray so that he would achieve all his desires. This is a similarity between the two works because Christianity is portrayed as a powerful solution to problems. It is important to note that, in their quest for freedom, these two people did not mind about hurting others. Finn is ready to sacrifice the relationship between himself and the woman Watson. Despite the fact that she takes care of him, he still proceeds with an oath that has her as the ideal seal. On the

Community Counseling Essay Example | Topics and Well Written Essays - 750 words

Community Counseling - Essay Example An important aspect of modern counseling philosophy is that the clients remain in control of their own treatment program. This is a recognition of the importance of cooperation in the counseling relationship and gives the client a sense of responsibility in there own lives. This freedom of choice for the client increases their stake in the interventions and the outcome. This puts the client in the driver's seat. The counselor does not dictate actions, but merely acts as a facilitator for change. The philosophy of counseling is client oriented, and the role of the counselor is to promote a since of wellness and show a commitment to improving the lives of their clients. The overriding principles that drive the counseling relationship are genuineness, respect, dignity, and client self-worth. This idea is open to all individuals regardless of ethnic, cultural, racial, sexual and special needs. Counseling emphasizes unconditional positive regard, respect, a safe and caring therapeutic relationship, individual strengths, and taking control over choices. Professional organizations set up accrediting agencies to promote, evaluate, audit, and certify institutions and programs that meet professionally recognized criteria. Programs that meet accreditation standards reassure the university faculty and students that they are being taught the skills that are needed to the current industry acceptable standards. This makes it easier for a student that goes through a CACREP program to be recognized as having the necessary skills and knowledge to pass a certification test. One of the benefits of this program is that you know that you would be going through a well-rounded educational experience. Another benefit is that the program is monitored and set up in a way that has a strategic plan that is oriented for the success of the students. Membership in a professional association and credentialing is an excellent method for the profession to remain ethical and well regulated. It is sometimes easy to forget our ethics and fail to act in the best interest of our clients. Personal gain, self-aggrandizement, and lack of ethical education can all contribute to problems of professionalism. While credentials are a necessary part of career advancement and certification, they should not be used as a substitute for competence and caring. In the counseling profession, the law will occasionally come into conflict with the code of ethics. This means that you may have to violate the law to remain true to your own sense of morality. The counselor must be able to justify their ethical decisions and be prepared to suffer any professional or legal consequences that may arise. Community Work Settings Community counselors work in settings that may range from individual sessions, families, groups, and communities. Community counselors can perform many tasks that include vocational, psychological, emotional, prevention, and intervention activities. Community counselors take a role as a community activist to promote positive social change within the society. Community counselors confront issues such as drug and alcohol abuse, domestic violence, and sexual abuse. This may occur in a hospital, community center, or a correctional facility. The value of early intervention has highlighted the importance of counseling moving into the school system. This would be

Christinity and Culture Essay Example | Topics and Well Written Essays - 750 words

Christinity and Culture - Essay Example Kierkegaard, in his book 'The Sickness unto Death' likens the fears of the Christian to those of a non-believer in the Christian religion to the fears of an adult and those of a child; children fear things that might not be harmful to them like darkness and some creations of their minds, while the adult fears what is really terrifying. It is evident from this that Kierkegaard believes that the world view of Christianity is different from that of other religions, cultures and philosophies, and - according to Kierkegaard - is superior. Kierkegaard is a Christian who is not willing to compromise any aspect of his religious belief. Some Christians however, either for making their religions more popular and applicable or for a conflict within them between their cultures and their religions, have sought to bring Christianity's view of the world closer to their cultural one. There has been many tries to do this while maintaining harmony with the Christian view, such as arguing that culture is the creation of God and so it is not against his will to follow it. All these views however fail to maintain logical consistency for a simple reason; Christianity claims to be from an all-wise God and thus claims perfection, it also claims that every human has free will but is required to follow the path set by God. To argue that man is imperfect and should follow his imperfect path is at bottom saying that Christianity is a perfect law that has no use to us humans, that for some reason God asked us to follow this law and rewards and punishes based on the following of this law, and in the same breath saying; God wants us to ignore this law. Nietzsche's famous quote 'Only something which does not have a history can be defined' means that something that has evolved over time and will probably continue to evolve cannot be limited to a certain definition since it is in constant change. Morality is one such thing, and so, for Nietzsche, the Christian - or any religious - attempt to define the morality of all time fails. This can be contrasted with Kierkegaard's view that Christianity is superior to any other philosophy, morality or culture. There is no middle ground, and trying to seek in holy books a hint for going against them is like asking God to give us orders and ask us not to follow them. What if these tries do succeed, and so one of the orders given to us by God would be 'don't follow my orders', what then should we do Back to the problem that initiated this ethical religious problem, if Catholicism is to be taught in Catholic schools, then a kid with lesbian parents will definitely suffer in that school from hearing that his own parents are going against the very teachings of his religion. If, however, Catholicism must be changed to suite the needs of people who both want to claim to follow a religion and go against it then we are left with something that is not Catholicism but that has the same name. Some people act as if one should be given the right to be Christian and have a belief system that goes against Christianity, but I believe that if someone has a belief system that goes against a religion then he is, by that fact alone, not belonging to

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

Soylent Green & Euthanasia

English 20 Soylent Green & Euthanasia Soylent Green was based on the short story by Harry Harrison entitled â€Å"Make Room! Make Room! † It offers solutions to many near future problems. Overpopulation is one. Euthanasia is another. Feeding the masses is yet another. In fact euthanasia is a solution to the problem of overcrowding. What I choose to deal with here is euthanasia. Simonson, a character in the book, helps himself to the latter's food, liquor, bathroom, and books. Through this he discovers the nefarious deeds of the Soylent Company, The entity that feeds people.He treats it as a necessary evil. A concept that pulls the hearts strings of all readers. In the story food is provided for the overpopulated world by a lottery where old people are killed in euphoric ways to provide food. The meals are called Soylent green. Some people are aware of what the lottery is for, some are not. These are important for the fact that overpopulation in today’s society is alread y a problem. I will address that later. The movie is very disturbing. The idea that humans are food for other humans strikes the wrong cord in the reader, as it should.That is the author’s intention. The movie and the story are made to provoke a viewer to think about different perspectives. The one that stuck with me the most is Euthanasia. I disagree with the author’s inedited meaning. Personally I feel that euthanasia should be allowed. Not out of necessity but because people should not suffer. To address the modern day relevancy it must be mentioned at the time of the book and movie. It was understood mathematically that eventually there would be too many people to feed.It is the same way today and the number of people that are growing every year is such that it is exponentially. Also euthanasia is constantly debated today. Some people believe that it is an issue reserved for only Gods judgment. I. E. it will never be a human beings decision. The other point of view is that free choice is what is given by god. Again the author is not debating those two issues when it comes to euthanasia. He is debating the first I mentioned. That euthanasia is a moral issue vs. the issue of human survival. Euthanasia is a religious, ethical, and moral issue in this county.It is one that is shunned by our society in the fact that no one wants to talk about it. The view of many Christians is that when you are called to heaven it is your turn. However, the last six months of your life are usually the most expensive time of life. A person can live a century and in that time, become incapacitated of time and place. In this instance, the physician and government officials have to make the decision to euthanize. Morally, families usually decide and carry out loved one’s last wishes. Funeral’s are arranged, people die, are remembered, and then buried.It needs to be noted that in many European counties euthanasia is allowed. A kindly death for the elderly is the European sentimentality. Personally I agree with the concept. The movie treats it in a way that is defiantly negative. Again I agree with euthanasia, a safe comfortable death for those at the end of their life. The movie showed the detrimental side of euthanasia. The fact that the people were not aware of being turned into food is humorous. Truly, I find it hilarious. The story is one that shows the dangers of overpopulation and government control.Forgive me again, for laughing but the irony that is inherent in the movie makes me laugh to no end. Actually what harm is done by people becoming food unwillingly? IT needs to be noted that in the movie Dr. Pianka had mixed feelings about the creation of Soylent green. On one he had was feeding the multitude; on the other hand he was taking lives. How would you feel about such a dichotomy? Personally I feel that the ends justify the means. Truly, debating the intention of the debating author is clear. He hopes that this future is one that WILL not happen! At the same time HarryHarrison realizes it is a possibility. This is Something that we as humans should be aware of. The possibility that people could be sterilized by the true â€Å"progressives† is truly disturbing. In conclusion, Soylent Green is a movie that provokes the mind, spirit, and soul. The truth that the world will soon be overpopulated is so close to coming true! The creators of the movie show that. It wants nothing more for us; as human beings to understand that this is an issue that will have to be dealt with eventually. Also it wants us to understand that not every option is the best option.