The Uses Of Bernoullis Principle Engineering Essay

The Uses Of Bernoullis ruler Engineering EssayAirplanes scratch off a heaving lodge on their flanks, keeping them up in the air, if they are moving at a sufficient high speed relative to the air and the wing is tilt upwardly at a small angle, the angle of attack. The upward tilt, as well as the rounded upper surface of the wing, causes the streamlines to be durabilityd upward and to be crowded together above the wing. The area of air light between any two streamlines is reduced as the streamlines are squished together. Because the air speed is greater above the wing than on a trim floor it, the extort above the wing is less than the mash below the wing, which is Bernoullis principle. Hence, there is a net upward force on the wing called dynamic lift. Experiments show that the speed of air above the wing put forward even be double the speed of the air below it. Friction between the air and wings exerts a drag force, toward the rear, which must be over come by the plan es engines. A flat wing, or the unity with symmetric cross section, will experience lift as long as the fron of the wing is tilted even if the attack angle is zero, because the rounded upper surface deflects air up, squeezing the streamlines together. AirplanesBaseball CurveWhy a spinning pitched baseball (or tennis ball) curves net also be explained using Bernoullis principle. It is simplest if we put ourselves in the reference frame of the ball, with the air rushing by. Suppose the ball is rotating counterclockwise. A thin layer of air is cosmos dragged around by the ball. We are looking down in the baLack of blood to the adeptIn medicine, one of many applications of Bernoullis principle is to explain a TIA, a transient ischemic attack (meaning a temporary lack of blood supply to the brain). A person suffering a TIA may experience symptoms much(prenominal) as dizziness, double vision, headache and a weakness of the limbs. A TIA can occur as follows. Blood normally melts up to the brain at the back of the head via the two vertebral arteries one going up each side of the neck which meet to form the basilar artery just below the brain. The vertebral arteries issue from the subclavian arteries before the latter pass to the harness. When as arm is exercised vigorously, blood flow increases to meet the needs of the arms muscles. If the subclavian artery on one side of the body is partial blocked, however, as in arteriosclerosis (hardening of the arteries), the blood speed will invite to be higher on that side to supply the needed blood. The increase blood velocity past the opening to the vertebral artery results in lower compel (Bernoullis principle). Thus, blood rising in the vertebral artery on the good side at normal pressure can be diverted down into the other vertebral artery because of the low pressure on that side, instead of passing upward to the brain. Hence the blood supply to the brain is reduced.Other ApplicationsA venture tube is essenti ally a pipe up with a narrow constriction (the throat). The flowing air speeds up as it passes through this constriction, so the pressure is lower in the throat. A venturi meter, is utilize to measure the flow speed f gases and liquids, including blood velocity in arteries. Why does smoke go up a chimney? Its partly because hot air rises (its less dense and therefore buoyant). But Bernoullis principle also plays a role. When slue blows across the conduct of the chimney, the pressure is less there than inside the house. Hence, air and smoke are pushed up the chimney by the higher indoor pressure. Even on an plain still night there is usually enough ambient air flow at the top of a chimney to assist upward flow of smoke.If gophers, prairieBernoullis principle, physical principle formulated by Daniel Bernoulli that states that as the speed of a moving facile (liquid or gas) increases, the pressure within the fluid decreases. The phenomenon described by Bernoullis principle has man y practical applications it is employed in the carburetor and the atomizer, in which air is the moving fluid, and in the aspirator, in which water is the moving fluid. In the early two devices air moving through a tube passes through a constriction, which causes an increase in speed and a corresponding reduction in pressure. As a result, liquid is forced up into the air stream (through a narrow tube that leads from the body of the liquid to the constriction) by the greater atmospheric pressure on the surface of the liquid. In the aspirator air is drawn into a stream of water as the water flows through a constriction. Bernoullis principle can be explained in terms of the law of conservation of energy (see conservation laws, in physics). As a fluid moves from a wider pipe into a narrower pipe or a constriction, a corresponding volume must move a greater distance forward in the narrower pipe and thus have a greater speed. At the same time, the work done by corresponding volumes in th e wider and narrower pipes will be expressed by the product of the pressure and the volume. Since the speed is greater in the narrower pipe, the kinetic energy of that volume is greater. Then, by the law of conservation of energy, this increase in kinetic energy must be balanced by a decrease in the pressure-volume product, or, since the volumes are equal, by a decrease in pressure.Daniel Bernoulli formulated a principle that states that as the velocity of moving fluid or gas is increased, the pressure within the fluid or gas is decreased. Bernoullis principle has in fact many practical applications it is utilize in the carburetor and the atomizer, in which air acts as the moving fluid, and in the aspirator, water is acting as the moving fluid. In the carburetor and atomizer, air locomotion through a tube goes through a constriction, which causes an increase in the velocity, and a decrease in the pressure. As a result, the liquid is forced up into the air stream (through a narrow t ube that leads from the body of the liquid to the constriction) by the greater atmospheric pressure acting on the liquid.In contemporary everyday life there are many observations that can be successfully explained by application of Bernoullis principle, even though no real fluid is entirely inviscid 19 and a small viscosity often has a large effect on the flow.Bernoullis Principle can be used to calculate the lift force on an airfoil if you know the behavior of the fluid flow in the vicinity of the foil. For example, if the air flowing past the top surface of an aircraft wing is moving faster than the air flowing past the bottom surface then Bernoullis principle implies that the pressure on the surfaces of the wing will be lower above than below. This pressure difference results in an upwards lift force.nb 1HYPERLINK cite_note-2020 Whenever the distribution of speed past the top and bottom surfaces of a wing is known, the lift forces can be calculated (to a good approximation) usin g Bernoullis equations21 established by Bernoulli over a century before the first man-made wings were used for the purpose of flight. Bernoullis principle does not explain why the air flows faster past the top of the wing and slower past the underside. To date why, it is helpful to understand circulation, the Kutta condition, and the Kutta-Joukowski theorem.The carburetor used in many reciprocating engines contains a venturi to create a region of low pressure to draw fuel into the carburetor and mix it good with the incoming air. The low pressure in the throat of a venturi can be explained by Bernoullis principle in the narrow throat, the air is moving at its fastest speed and therefore it is at its lowest pressure.The Pitot tube and static port on an aircraft are used to determine the airspeed of the aircraft. These two devices are attached to the airspeed indicator which determines the dynamic pressure of the airflow past the aircraft. Dynamic pressure is the difference between stagnation pressure and static pressure. Bernoullis principle is used to calib measure the airspeed indicator so that it displays the indicated airspeed appropriate to the dynamic pressure.22The flow speed of a fluid can be measured using a device such as a Venturi meter or an orifice plate, which can be placed into a pipeline to reduce the diameter of the flow. For a horizontal device, the doggedness equation shows that for an incompressible fluid, the reduction in diameter will cause an increase in the fluid flow speed. Subsequently Bernoullis principle then shows that there must be a decrease in the pressure in the reduced diameter region. This phenomenon is known as the Venturi effect.The maximum possible drain rate for a tank with a hole or tap at the base can be calculated directly from Bernoullis equation, and is found to be proportional to the square root of the height of the fluid in the tank. This is TorricelliHYPERLINK http//en.wikipedia.org/wiki/Torricellis_lawHYPERLI NK http//en.wikipedia.org/wiki/Torricellis_laws law, showing that Torricellis law is compatible with Bernoullis principle. Viscosity lowers this drain rate. This is reflected in the discharge coefficient which is a function of the Reynolds enumerate and the shape of the orifice.23In open-channel hydraulics, a detailed analysis of the Bernoulli theorem and its extension were recently developed.24 It was proved that the depth-averaged specific energy reaches a minimum in converging accelerating free-surface flow over weirs and flumes (also 25HYPERLINK cite_note-Chanson2006-2626). Further, in general, a channel control with minimum specific energy in curvilinear flow is not isolated from water waves, as customary state in open-channel hydraulics.The principle also makes it possible for sail-powered craft to travel faster than the wind that propels them (if friction can be sufficiently reduced). If the wind passing in front of the sail is fast enough to experience a significant reducti on in pressure, the sail is pulled forward, in addition to being pushed from behind. Although boats in water must contend with the friction of the water along the hull, ice sailing and land sailing vehicles can travel faster than the wind.27HYPERLINK cite_note-2828Bernoullis Principle

Elements Of The Extended Marketing Mix Marketing Essay

Elements Of The Extended Marketing Mix Marketing EssayThe elements of the extended merchandising mix (the 7ps) which be sink, Product, Place, advancement, People, Processes, Physical induction provide be developed, how they helps to examine the stages and steps in planning, also understand how those different stages of the marketing planning fit together and related to the overall physical com layional planning framework.In this report one will understand what strategies and techniques should be used to successfully run a business. It shows bar assumeer behavior and what its all close to, what motivates consumers to buy and why the buy, and how pricing can be a key on consumers reactions to the clubs run, without forget that node service and promotion as necessity too as they help in the awareness, audiences image of the business, satisfy them and create that strong relationship with the consumers.2.0 Buyer behaviorBuyer behavior is the behavior that consumers display in seeking, purchasing, using, evaluating and disposing of point of intersection or services that they expect will satisfy their mortalal needs.Buyer behavior has environmental influences such asSocial-cultural, the for mountain to conform to norm and neighborly themes.Economical and competitive influences, during a recession consumers capability be more than reticent about purchasing expensive things.Technological influences, where technology allow family to create a personal relationship with consumers.Political and regulatory, a backing of regulatory body can give reassurance to consumers.Seeking for information about what people want and what can influence them, see how people response to your services and performance is very important.In the buyer behavior, problem solving take a big part, it tend to day to day purchase and services, how to reduced risk, set a low price. And also giving consumers consumer services the way they expected or impress them more.The limited prob lem solving buying situations is necessary like buying situations that happened less frequently as a TV, ect where it can reach more deliberate decision, always remember that The impact of a satisfied customer is that he/she can tell up to other people about their experience, and make them take their way to the company.MaslowFig1. What affect the consumer buying behavior.2.1 Application of the buyer behavior on the fitness clubIn your new business, success could be archived if its focused upon customers orientation, needs and satisfaction, only if in order to investigate customers information to help the club track consumers it is advantageous to break down the purchase work at to a framework so as to simplify the factor and process influencing purchase behavior. Identify the different types of customers and take the need for customers to conform with norms of social groups. section will be useful for your business, the most importance there is to know and alert the needs of dif ferent buyer groups, therefore the fitness club could plane section its customers as in social economics buyers group of age, culture, sex, income level, occupation, family size,I would recommend the club to go with differentiated marketing strategy of segmentation, where varieties of services are abandoned and differentiated by prices, quality, and so the club can give different tariff to suit different groups of people in the South East London.You will need to create a strong problem recognition to identify problems from and immediately look for a solution. Your challenge will be to understand how customers might respond to your different element of marketing mix.Watch your service availability and all the service dealing with suppliers to ensure the services will be give to customers at the unspoilt time and how they wish in order to maintain that strong customer relationships and make them have total assurance and trust with you.3.0 promotional materialIs the a range of ta ctical marketing techniques designed within a strategic marketing framework to add value to yield and service in order to achieve specific sales and marketing objectives. Frances Branssington.FPettitt.S (2006)The promotion influences the consumers, build long term awareness and market share, generate quick sales bursts, and gain rectifyrd purchase and better in store display, to generate new andrenewed interest in product and service, as well as increase sales. Consumer attitudes and buying patterns.For an effective promotion the understand a target audience is necessity, indentify resource constraints, establish objectives, select method and evaluate the program after successful. progress increases sales so that advertising and other costs are spread over a larger output. Though increased promotional activity is a sign of a response to a problem such as competition, it enables an organization to develop and build up a succession of messages and can be cost-effective.In developm ent of a sale promotion the following points should be kept in mindThe brand strategies.The competitive strategies.The advertising strategies.The pricing. www.marketingdonut.co.uk/marketing strategy.Promotion are designed to motivate consumers to an immediate action. Therefore Gaining new customers, retaining current ones, increasing consumption, increasing brand awareness using refund and premium offers, group promotion, loyalty incentives, temporary price discounting, using point of purchase(posters), increasing attention from broadening distri saveion channels and intermediaries is extremely important.3.1 How to promote the fitness club later understanding who you need to reach and what you are trying to achieve. Ensure that customers are aware of you, what you can offer and how you differ from competitors and create opportunities to generate repeat and spicy purchases. Once that, find yourself promoting individual services differently to different groups of customers and to add value to the fitness clubYou could also promote you business in person by pitching directly to target consumers, or get introduction and creating relationship through networking, or using a range of different promotional techniques to reach large audiences such as direct mail, advertising, exhibiting your business or online marketing.Timing is also an important element when promoting, you should also make sure your marketing message reach to your target consumers when they are most receptive.Crucially your promotional strategy should include the way to measure the effectiveness of what you have been doing.And you should monitor your website profession and use surveys to tell you how your promotional activities have influenced consumer attitudes and awareness like its helps you understand which part of your promotional strategy is working or not and how you can improve.4.0 customer ServiceCustomer Service is the commitment to providing value added services to external and internal customers, including attitude knowledge, technical support and quality of service in a timely manner, its also about treating others the way you would like to be treated yourself. http//www. Costomerservicemanager.com/definition4.1 Roles of Customer Service in the Fitness ClubFor a steady-going customer service you should first know that without beloved customer service, a business could not survive.A satisfied customer would be more smart to take part in activities that help to generate customer preference data. This data will do back to the marketing function and could help the organization to better draw and quarter and target it potential customers.It is clear that a customer who has been provided with a service that he desired in the ideal way, would build a relationship with the seller and can support continued purchases and revenue or giving new ideas for new services .Additionally, The customers will have a earnest experience and will feel that the club treated him wel l and as a happy and satisfied customer is more likely to send more customers your way, hence the club will have well-grounded reputation and will get new customer where more purchase. In fact customers who had bad experiences are double as likely to tell others about it as customer involved but perhaps another twenty too.To establish a good customer care and service you will also need to indentify customer needs and perception, you should establish with precision what are customers satisfaction and what are their expectation, and must consider their perceptions and standard of customer care to know how you could improve. Lancaster G, Massingham L, Ashford.R (2002)Before you can improve your customer service, you have to find out what its like at this point in time for customers to do business with you. The best way to do it is to interview your customers. To provides suggestions for feedback from your customers. When youre seeking your customers views of your customer service, rem ember that customers measure customer service in specifics, a customer doesnt rate your customer service as good, fair or poor he or she pays attention to how you answer the phone or how he or she was treated when asking for helpSo when youre adapting the customer service survey form I provide to suit your own needs or talking to customers in person, be sure to ask specific questions about specific customer service situations. Not How was our customer service today? but Did the person who was helping you answer all your questions? http//sbinfocanada.about.comFor example you can focus on a customer wanting help, answering the phone, and a customer qualification a return or complaint in this Customer Service Makeover because these three are most common customer contact points.5.0 Pricing procedures.Price is the odd-one -out of the marketing mix, because it is revenue earner.The price of a product is what a company gets back in return for all the effort that is put into manufacturing and marketing the product. As we shall see, price is an important part of positioning strategy since it often sends quality cues to customer. Jobber D(2001)External situation, where it focus on customers and competitors, how the ask and price elasticity are, how to attract customers and make them response positively to a product or service.Internal where the organization need to set a price that generate profit, where marketing objectives, costs, pay , production, distribution.In determining price there is 5 main steps To have pricing objectives.The demand assessment.The pricing strategies and policies.The pricing tactics and adjustment s. riding horse the price.The price have to be set properly as it can be difficult to change later, and low to attract new customers and push competitors but can establish perception and attitude of the quality and standard of the brand. knowing that the level of innovation can influence the price of a new product or service.The price can be a key competitive in securing market as customer can have a posit reactivity to product and service due to the price levels, because when it linked to completion pricing provides a powerful market orientation perspective.One can set a price above the market but providing something that other competitors dont have. And can also make people ready about any change in price.CostCompetitorMarketingPricing methodsFig2. Pricing methods.5.1 Pricing in The Fitness ClubFor a better clubs pricing strategy you should first have pricing objectives link with organizational and marketing objectives where some may be financially or related to sales, your pricing objectives will implicate also production, finance and distribution.Here are general sequence of steps to follow for developing the pricing of your servicesDevelop marketing strategy.Make marketing mix decision. estimate the demand curve.Calculate cost.Understand environmental factors.Set pricing objectives.Determine pricing. http/www. Netmba.co m/marketing/pricing.It is very important for you to get set up your price right and surely because it could be difficult for you to change them after as it could push consumers. Only the level of introduction later could influence the price of new services to the club.Set up low prices to attract new customers and let them compare with competitors and make their way to you, but without forgetting the business profits too.Buy referring on the consumers responsiveness to different price level it will give you a powerful market oriented perspective on pricing your services..because we cant ignore that the demand can increase basing on the cost of services.Occasional promotion price could be necessary to motivate consumers to purchase more and to create a good relationship with them. That can favorite awareness and give a good image of your club to t outside audience.6.0 ConclusionDiscussing all the related factors and ground you should now get an ideas over the fitnesss business in ma rketing term, and that could be useful in the planning process, by applying them in proper ways you should improve without complication and quickly get used to the routine of day to day activities in your business.References.-David Jobber 2001, Principal and Practices of Marketing 3ed,McGraw-Hill, England, p318-Frances BranssingtonStephen Pettitt 2006, Principles of Marketing 4ed, pearson education, England,p720-George Lancaster, Lester Massingham, Ruth Ashford 2002, The Essentials of Marketing 4ed,Mc Graw-hill, UK-http//www. Costomerservicemanager.com/definition, customer service. http//www.marketingdonut.co.uk/marketing strategies.-http//www. Netmba.com/marketing/pricing..Bibliography.-Frances.B Stephen. P 2003, Principles of Marketing 3ed, Pearson Education ltd, UK,p652-William.D.P,Jr.Jerome .M 1999, Basic Marketing/A Global-managerial Approach 13ed, Mc Graw-hill,USA ,p155

Antidepressants for Postnatal Depression

Antidepressants for postpartum imprintAntidepressants be they a safe and potent choice for the preaching of postnatal depressive disorder?This appraise taxed the rise concerning the erectivity and safety of antidepressants in the anxiety of postnatal effect. This would facilitate evidence- ground clinical decisions in the discussion of patients. Data was sourced from several electronic Athens- ground and free informationbases c everyplaceing the psycho-biomedical and nursing books.Studies base included randomise clinical trials, case- and cohort- engage lead studies, questionnaire surveys, and qualitative/exploratory research. Previous go overs were as well appraised. Outcomes from over 1200 stupefys, develop-infant pairings, or infants, bottomdid to antidepressants were con emplacementred. Antidepressants front to signifi put uptly exc consumption depressive symptoms. Further more than, the surveyed brass effectuate atomic number 18 ecumenically benign and clinically in portentous. However, methodological and analytic flaws do in decisive inferences.Many studies fail to mark for important covariates that may explain do attri thoed to antidepressants. furthermore, most studies fail to account for interactions in the midst of antidepressants and patient characteristics, which may debunk more sedate untoward personal effect. Additionally, t present 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 be phthisisd as a last resort, and patients be closely monitored to send unexpected side effects, or retrieval induced by covariates rather than antidepressants.Chapter mavinIntroduction, Rationale, AIMSIntroductionAccording to Beckford-ball (2000) postnatal depression (PND) fails to attract public worry beca routine it is associated with a positive event claw abide nonwithstandi ng the evidence that a good majority of women visit this phenomenon after delivering their baby (RCP , 2004). Nevertheless postnatal depression, if leftfield untreated, can gather in adverse effects for mother-child relationship and infant victimisation (Green, 1995).This drawing reviews evidence concerning the safety and strength 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 belie conclusive inferences on the subject.AntidepressantsAccording to the RCP antidepressants atomic number 18 drugs developed in the mid-fifties for treating symptoms of depression (RCP, 2006).They stimulate by stimulating neurotransmitters in the brain. trey main types of antidepressants are specified 1. Tricyclics (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 common chord months of intervention 50% to 65%of tribe given an antidepressant show improvements in mood, compared with 25% to 30% of lot 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, e peculiar(prenominal)ly if in that location is an overdose.However, all four classes of antidepressants are considered to take a leak by-products, such as tall blood pressure, anxiety, indigestion, dry mouth, heart tremor, and sleepiness. Most of the adverse effects are considered mild and expected to dissipate after a few(prenominal) weeks.The RCP cites evidence of masturbation symptoms in infants tersely after hold, especially with paroxetine (RCP, 2006). Babies can also line up a morsel 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, white plague of antidepressants during breastfeeding is not discouraged. more or less pregnant women suffer a recurrence of depressive symptoms, and on that pointfore may need to take antidepressants continually.The National Institute for clinical Excellence (NICE, 2004) has published guidelines for the discussion of depression. However, there is no special accent mark on pregnancy-related depression. Antenatal and postnatal guidelines are due to be published by 2007 (Green, 2005).Postnatal DepressionAccording to the RCP (2004) postnatal depression (PND) is what happens when you become discourage after having a baby (p.1). It is quite common, affecting circa 10% of parvenuely delivered mothers, and can last for several months or longer if untreated. Symptoms include feeling downhearted (unhappy, low, wretched, with symptoms becoming worse at particular condemnations of the twenty-four hour closure), irritable(heightened sensitivity, especially to benign comments by others),tiredness, sleeplessness (late retirements, early rises), and lack of appetite and interest in cozy intercourse. Many women may feel they are unable to cope with the revolutionary situation, or even experience anxiety and detachment towards the infant.Various ca drills of PND wear been set including a forward narration of depression, not having a supportive partner, having a wild infant or premature delivery, losing unitys own mother as a child, and stressful demeanor 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 pegs ( Beckford-Ball, 2000 Green, 2005)1. postpartum blues 2. Postnatal depression 3. Puerperal psychosis.Postpartum blues 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 victimization hormone replacement therapy.Postnatal depression is less frequent, and emerges as a deep and protracted sadness which is a great deal more intense and persistent than postpartum blues and its symptoms rarely settle 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 discourse 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 entre to a psychiatric institution and treatment with antidepressants and other drugs.RationaleDespite drop off guidelines regarding the use of antidepressants during pregnancy it is necessary to appraise existing literature on the topic, for several reasons1. Limited stage setting of existing reviews. 2. Identification of gaps and inconsistencies in the literature 3. stay of live claims and guidelines, for example by the RCP, regarding the musical compositionagement of postnatal depression.Limited scopePrevious literature reviews are considered in this brief (see Chapter 3). Most reviews are restrict in scope mainly because they focus on studies victimisation 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 la seek literature.Identification of gaps and inconsistenciesPrevious reviews on the topic have highlighted problems that need to be turn to 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 frame little evidence of mal spirtations 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 claimsThe RCP publishes an information guide for the use of antidepressants. Various claims are made regarding safety and efficacy of use during/after pregnancy, tenacious with NICE(2004) standards. While most assertions are based on research evidence there is a need f or on-going reviews that highlight recent findings and consider their implications for existing guidelines.Some of the trace pronouncements and guidelines are as follows1. 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.AimThe aim of the current review was to appraise evidence on the safety and effectiveness of antidepressants in the management of PND.Chapter TwoLiterature ReviewT he evidence/data to be reviewed here is based on a comprehensive search of multiple databases including HIGHWIRE tender, ACADEMIC hunt PREMIER ( retrieve 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 defend 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 abnormal psychology, PND is comprehensively addressed. INTERNURSE leaves 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 favourite(a) 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 reviewed1. Empirical studies exploitation either qualitative or quantitative methods. Thus, this included case studies, questionnaire surveys, retrospective/ likely designs, and randomised controlled trials(RCT).2. Review articles and meta- summa ry, 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 wellness (DOH), National Institute of Clinical Excellence(NICE), and the Royal College of Psychiatrists (RCP).The emphasis was on the function 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 reviewThe safety and effectiveness of antidepressants can easily be established by conducting an original empirical use up. However, individual studies are severely constrained in scope and will ultimately provide a snap-shot or localised insigh t on the subject. Moreover, scientific knowledge advances from the accruement 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 hold greater importance.Depression as a topic has been heavily researched. legion(predicate) studies have been published on antidepressants and PND. The multiplicity of published literature reviews on antidepressants/PND attests to the copiousness of empirical evidence on the topic. Thus, attempting to establish the safety and efficacy of antidepressants on the basis of a single say would still require an understanding of what has been through 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 birds mall view of the available evidence, fall upon gaps in the literature, and highlight avenues for further research (Cool can, 1994).personal effects of anti-depressantsAppleby et al (1997) conducted a randomised control trial to quantify the effects of fluoxetine and cognitive-behavioural counselling on postnatal depression. Another aim was to compare fluoxetine and placebo assorts, 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 medical 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 tons were interviewed using a rewrite clinical sche dule, 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 assign to one of four experimental conditions fluoxetine, placebo, one counselling session, and sixer 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 naval division for repeated placards (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 themes. Fluoxetine produced better improvement compared with the placebo the percentage (geometric) differences in means gobs based on the revised clinical interv iew 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 this study shows the effectiveness of both fluoxetine and cognitive-behavioural counselling in the treatment of women rear 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 smart variance, through strict eligibility criteria, it would have been useful to incorporate detailed terra firma 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 importation of these variables, and the unique contribution of SSRI treatment after peremptory 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 Childrens Abilities (measures IQ), and the Rendell Developmental Language Scales.Results revealed no significant ag pigeonholing 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 multitudes of mother-child pairs were recruited. The first two groups were displace from the Mothers Program, a scheme that provides support to women suffering from major depression. All women recruited from this architectural plan 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), motion picture to chemical or ray pollution, or severe health problems likely to affect fatal development. This group was randomly selected from among visitors to the authors clinic. Women who had give up the use of antidepressants after concep tion 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, antepartum and postnatal assessments, neurobehavioral tests (Bailey Scales of Infant Development, McCarthy Scales of Childrens Abilities, age-appropriate Achenbach Child Behaviour Checklist), and follow-up test of them other (Wechsler Adult Intelligence Scale, and other measures). A one-way analysis of variance was utilise to compare outcome measures across the three groups. Correlational and atavism tests were used to assess the contribution of confounding variables.Results revealed no group differences in childs global IQ, language development, or behaviour (see take to 1). The authors concluded, delineation to tricyclic antidepressants or fluoxetine throughout the gestation period does not appear to adversely affect cognition, language development, or the temperam ent of preschool and early-school children. Although regression was used to account for the contribution of confounding factors, such as verbal comprehension and communicative language, the variance explained by these variables was not in fact partial led out before testing for group differences.This would have required a variable analysis of covariance in which adjustments for covariates are built into the analysis. More importantly, the observed relation in outcomes across the three groups may reflect simple or mixed 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 pr eviously had at least one depressive chronological succession. 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 psychopathol ogy (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 Fishers 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 early 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 tre atment 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) tried the effect of SSRI film on bio behavioural responses to acute adjectival pang in new-born babies at2 months of age. Previous research has suggested altered behavioural and physiological reactions to a routine paroxysmful event in infants, after prenatal exposure to SSRI antidepressants. There is paucity of literature on the long-term effects of SSRIs on neuro behav ioural 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 growth 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 rateHR, 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 allow neuro behavioural SSRI effects that extend beyond the new-born phase. Oberlander et alls(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. just age was 28.6 years, and most women were married and Caucasian (73%).Screening took place at roughly 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 heading 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 antidepressa nts 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 pore 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, whole step 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 t hat certain assumptions which underlie use of the t-Test were violated, notably homogeneity of variance. The gigantic disparity in group sizes (268 versus 68) hugely make ups 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 womens self-reports of medication use, with no familial, clinical, or other verification. Its therefore unclear to what limit 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 Kostass, 2002 Hendricks, 2003 Bennett et al, 2004 Cohen, 2005Marcus et al, 2005) to comprehensive and doctrinal 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 anecdotical reports.Electronic databases searched included Medline, EMBASE, Darent 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(prenominal) 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 f atal development.However, these findings were inconclusive due to prior group differences on previous psychotropic drug use, and failure to control for depression levels. withal 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 malformationsAntidepressants for Postnatal DepressionAntidepressants for Pos tnatal DepressionAntidepressants 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.Man y 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 OneIntroduction, Rationale, AIMSIntroductionAccording 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 postna tal 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.AntidepressantsAccording 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. Tricyclics (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 Inhi bitors (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 DepressionAccording to the RCP (2004) postnatal depression (PND) 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 comme nts 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 ones 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 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 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.RationaleDespite clear guidelines regarding the use of antidepressants during pregnancy it is necessary to appr aise existing literature on the topic, for several reasons1. 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 scopePrevious 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 inconsistenciesPrevious 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 impli cations 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 claimsThe 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 follows1. 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.AimThe aim of the current review was to appraise evidence on the safety and effectiveness of antidepressants in the management of PND.Chapter TwoLiterature ReviewThe 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 postnat al 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 in corporates 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 reviewed1. 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 reviewThe 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 publis hed 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 birds eye view of the available evidence, identify gaps in the literature, and highlight avenues for further research (Cool can, 1994).Effects of anti-depressantsAppleby 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 thi s 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 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 Childrens 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) tr eatment, 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 authors 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 Childrens Abilities, age-appropriate Achenbach Child Behaviour Checklist), and follow-up testing of them other (Wechsler Adult Intelligence Scale, and other meas ures). 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 childs global IQ, language development, or behaviour (see Figure 1). The authors concluded, 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 sertra line 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 Fishers 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, an d1/14 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 recu rrence 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 rateHR, 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 alls(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 presen ce 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 comp romised 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 auth ors 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 womens 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 Kostass, 2002 Hendricks, 2003 Bennett et al, 2004 Cohen, 2005Marcus 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 i dentify 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, Darent 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 ano ther 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 paroxetin e, 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

The Mind-Body Connection :: essays research papers fc

The oral sex has an incredible power. We seeit as we go through our everyday activities,constantly displaying the wonders of logic,thought, memory and creativity. Yet, canthe mind be more brawny than we know?Is it possible to reduce or even eliminatepain, illness and disease by using thenatural powers it possesses? Can the mindheal? some of our finest researchers andscientists have explored that question, andwhile the exact answer still eludes us, thefacts seem to bear out that the mind doeshave the power to assist in both healing,and conversely, obstetrical delivery on "disease" aswell. Two such examples of mind and luggage compartmenthealing are hypnotherapy and meditation.There are others such as ionization, whichfocuses on cerebration positive instead ofnegative. But first, I will describe thereasoning behind the mind-bodyconnection.Psychoneuroimmunology is the name forthe study of the min-body connection, orPNI for short. PNI has been around for thelast 20 days or so and has revolutionizedthe way we look at health and wellness.There was a point in human existence whenthe connection between the mind and thebody was taken for granted. A couple ofcenturies ago, science had grown tounderstand the "mechanical humans"concept. The laws of Sir Newton and thescience of physics had begun to infiltrate thescience of medicine. If the universefollowed mechanical laws, so might thebody. To prove this theory, scientistsneeded to open a body up to observe how itworked. The Church was very adamantabout the body being the temple of the souland could never be desecrated. After muchhaggling and several smoke-filled backroom discussions, an agreement wasreached. The Church would confine itsjurisdiction over "the mind" for that is werethe personality and soul "truly" resides andscience could have the body, which is just a"machine for the mind" and upon death,would become evidently an empty vessel.Furthering the rift, more recent science hasdiscovered that specific diseases can be"cured" through specific medicinal formulasor drugs. This "magic lick" mentalityspread throughout medicine and science.Truly the body was a mechanical thing thatresponded to specific stimulus and could becounted on to respond the equivalent way everytime. Wonderful news, the body did notrespond as intended. Science has tried tobrush aside or explain away thisphenomenon y saying, "Oh, its just theplacebo effect" or "Its spontaneousremission" as well as other innocuous termsseemingly to diminish its importance. It ishuman nature when something is notunderstood to either dismiss it, diminish itor ignore it all together. This search to seekout answers to this reoccurringphenomenon is the soil for PNI, the waythe mind-body connection is made and how

The Conflict, Climax and Resolution in Oedipus Rex Essays -- Oedipus t

The Conflict, Climax and Resolution in Oedipus Rex Sophocles tragic drama, Oedipus Rex, presents a main conflict and lesser conflicts and their resolve after a climax. In Oedipus Tyrannus Tragic Heroism and the Limits of Knowledge, Charles Segal had the protagonist fares well in the first series of tests, but does poorly in the plump for series The first three tests are, respectively, Oedipus meetings with Creon, Teiresias, and then Creon again. In each case he is pursuing the killer as someone whom he assumes is opposite than himself. . . . The punt series begins with Jocasta and continues with the Corinthian messenger and Laius herdsman. Now Oedipus is pursuing the killer as possibly the same as himself. . . . In this set his goal shifts gradually from show the murderer to discovering his own parents. The confidence and power that he demonstrated in the first series of encounters gradually erode into anger, loss of control, and fear (72). With each of the six-spot encou nters the main conflict of the drama builds an inner conflict within the protagonist which involves his own mastery or hubris and humility or modesty before the the gods.Thomas van Nortwick in The Meaning of a Masculine Life describes Oedipus tragic flaw As ruler, he is a father to Thebes and its citizens, and like a father he will take care of his children. We see already the supreme self-confidence and ease of command in Oedipus, who can address not only other peoples children as his own, but also be a father to men older than he is. But beyond even this at that place is, in the sretched posture of the citizens, the hint of prostration before a deity. We are clinging to your altars, says the prie... ...homas Woodard. Englewood Cliffs, NJ Prentice-Hall, Inc., 1966. Ehrenberg, Victor. Sophoclean Rulers Oedipus. In Twentieth Century Interpretations of Oedipus Rex, edited by Michael J. OBrien. Englewood Cliffs, NJ Prentice-Hall, Inc., 1968. Jevons, Frank B. In Sophoclean Trage dy, Humans Create Their Own Fate. In Readings on Sophocles, edited by Don Nardo. San Diego, CA Greenhaven Press, 1997. Segal, Charles. Oedipus Tyrannus Tragic Heroism and the Limits of Knowledge. tonic York Twayne Publishers, 1993. Sophocles. Oedipus Rex. Transl. by F. Storr. no pag. http//etext.lib.virginia.edu/etcbin/browse-mixed new?tag=public&images=images/modeng&data=/texts/english/modeng/parsed&part=0&id=SopOedi Van Nortwick, Thomas. Oedipus The Meaning of a Masculine Life. Norman, OK University of okay Press, 1998.

How does Miller create dramatic tension between Marco and Eddie at the

How does Miller create dramatic stress between Marco and Eddie at theend of Act One?So farther in the play Marco and Rodolfo have illegally immigrated toAmerica, seeking shelter with their cousin Beatrice and her husbandEddie. Living with them is Catherine, their niece, who falls head overheels in love with Rodolfo. Eddie is not happy, as he is incrediblyoverprotective of Catherine. This overprotectiveness turns tojealousy, which turns into an obsession. At the end of Act One allfive characters are in the living room, sharing a cosy after dinnerchat.At this point of A View From The Bridge Eddie is feeling intenselyjealous of Rodolfo and he doesnt really apprehend why. He talks toAlfieri about it, yet Alfieri seems to immediately understand what isgoing on and just before this scene hints at the bloody outcome ofthis tale. Marco, too, recognizes Eddies feelings for Catherine,though he appears to be the only one in the family who sees it.The premonition in Alfieris soliloquy charte r the audience think. Itmakes them ask question standardised whos going to die? How are they going todie? Why are they going to die? The audience want to know the answersto all of these questions well(p) at the beginning of the play and willstart to guess what will happen, yet they have to pay attention tounderstand what is going on and make predictions.The personalities of the characters greatly affect the tension of thispart of the play. For example, if Marco were not so silent and still,his threat would not be so obvious. When he takes a chair, places itin seem of Eddie, and looks down at it it is a contrast to hisnatural behaviour. Eddie, however, still does not get it, as hebelieves that the worl... ...gland, for example, where the sense of community is muchless, the dramatic tension would not exist. In fact the situationwould probably not have arisen at all. Catherine would have had morefreedom, Eddie and Beatrice would have attended marriage counsellingand well-nigh ali ke(p)ly Marco and Rodolfo could have immigrated legally. Theplay would be quite boring.In conclusion, many things contribute to the tension at the end of ActOne. It would be nearly insufferable to have the same sort of tension ifjust one aspect of the play was changed. The tension would probablyremain but it would be utterly different. It could be more or lesseffective than the way it is now, but I feel it would be more likelythat a master playwright like Arthur Miller would understand what hewas doing, and would try and make the play as dramatic as he could, toget his point across.

Interpersonal Communication Demonstrated in the Movie, One Flew Over Th

Interpersonal Communication Demonstrated in the Movie, One Flew Over The Cuckoos NestCommunication is an essential part of our lives. It is through theprocess of communication that we argon able to make contact, and thus developwho we are in relationship to others. Interpersonal communication is aspecific sign of communication in which the people involved are contactingeach other as persons, and through an ongoing process, defining who theyare for each other.In the future(a) pages, I will explain six concepts related to the study of interpersonal communication. Following each explanation, I will give examples of how each concept is present in the movie, One FlewOver the Cuckoos Nest. In doing so, I hope to show that the conceptsintroduced in interpersonal communication can be applied to our popularlives.Personal versus Impersonal Communication Each twenty-four hour period we engage in various types of communication. Strange as it may sound, each time we speak with someone, we are not necessarily engaging them as a person. Sometimes, we just want to cash a check at the bank or pay for our groceries without creating anything deeper. separate times, we might want to discuss our feelings with a friend or introduce ourselves to someone new.Whatever the case may be, the type of communication that we engage in will be more personal at times, and more impersonal at other times. One way to envision this, is to imagine the communication events of our day lying somewhere on the impersonal--------------- interpersonal continuum. There are five characteristics that distinguish the personal from theimpersonal uniqueness, measurability, choice, reflectiveness, andaddressability. Uniquen... ...nherentlygood or bad, but each serves its declare oneself depending on the context in whichit occurs. Communication involves cues that can be best understood as parts of acontinuum. This continuum ranges from cues that are primarily verbal(words), to mixed(pitch , sound of voice), to primarily nonverbal (facialexpression, gestures, appearance). In any given communication situation,all of these ques work together in the process of negotiating selves. Thisprocess involves constructing and responding to definitions of ourselvesand definitions of the people we are communicating with. Contact and communication is what makes us human. The quality of ourcommunication is directly related to the quality of our lives, bothphysiologically and spiritually. For this reason, learning effectivecommunication skills should be grievous to all of us.