The many failures that lead to the disaster at the Royal Bank of Scotland finance

The many failures that lead to the disaster at the Royal Bank of Scotland payAmong the many failures that led to the disaster at the Royal Bank of Scotland, on that point was obviously a failure of unified governance. So it is only redress that, along with tout ensemble the other regulatory reviews, thither should be a review of the governance of embodied governance.In Britain, this is partly a occasion of self-regulation, with companies expected to follow the best practice corporate governance specimens target out in the so-called Combined Code.It is surely only a matter of time before some headline-grabbing politician identifies the root produce of all our problems we have been letting the rascals regulate themselves.So it is very fairish for the Financial Reporting Council, which acts as caretaker of the Code, to establish to get its retaliation in first. And it is very sensible that it will work closely with Sir David Walker, who is conducting a weaken review of gover nance of pious platitudes.Critics of the British approach to corporate governance oddly in America enjoy pointing out that RBS was, in fact, a exemplification pupil. It did everything by the book, ticked all the boxes and filled page after page of its annual report with an exhaustive analysis of its corporate governance performance.In particular, it had a separate, non-executive death chair a central pillar of the UK code, but far from standard practice in the United States a post is designed to stop an over-powery brain executive. Yet the RBS lead Sir Tom McKillop failed to restrain Sir Fred Goodwin, with catastrophic consequences for the bank and the taxpayer.American critics of the British system claim that we are so concentrate on ticking the boxes that it makes us complacent. It is one thing following all the rules, but cards also have to tell that they are working in practice. in that location are a few obvious areas the review should examine.The roles of chairm an, chief executive and senior non-executive director need to be better-defined. The code should advance non-execs to seek outside advice on big decisions. It should consider whether there should be special rules applying to banks it would clearly be advantageous if at least the chairman and members of the risk committee of banks had specialist experience.The review should consider ways to further more active involvement of shareholders in corporate governance questions. And non just traditional institutions, but also sovereign wealth gold and even hedge funds.The problem with all this is that, however they are organise boards are only as ingenuous as the practiced deal on them.And, for many curtilages, the job of non-executive director of a big company, let unsocial chairman of a bank, is not getting any more attractive. raze good people fail. Example is RBS board. It included the likes of Peter Sutherland and Sir Steve Robson. And, supportn that so many reputations ha ve been tarnished by the credit crisis, the pool of good people is shrinking.But it would be a mistake to allow the few good people to take on too many jobs. As chairman of BP, Mr Sutherland is direct supporting the reappointment as a director of Sir Tom, whom he helped to wrick chairman of RBS. Sir Tom, the man ultimately responsible for Sir Freds pension, even sits on the BP wage committee.Research Question and MethodologyRoyal bank of Scotland was a good example of following corporate governance which follows all the code of corporate governance. Despite this RBS had to bail out by taxpayer money, and majority of its share now owned by taxpayer. posting of directors of RBS was all outsiders and reputed on their own cogitation and there was no inner member on the Board. This proposal rear a report that RBS trader bought 34 billion pounds of sub-prime toxic as poses in US without informing its Board. The sub-prime assets are being blamed for causing the banks upright collapse in 2008. Last year RBS posted a discharge of 28 billion the largest in British corporate history.There whitethorn be a conflict between Board of members and Management. Maybe if there were member in Board from inside or from instruction this discommode in RBS might be avoided.This proposal will try to scrape up out structure and role of Board of Member and Management at RBS. And try to find out any conflict between Board and management which put RBS in turmoil.This proposal will try to question on theory of corporate governance and their practice at RBS try to find out the impact of corporate governance and its practice at RBS.This proposal will use secondary date for its quantitative research. belles-lettres ReviewCorporate Governance Board of DirectorsThe Corporate Governance is a wide and important subject that covers a range of issues from accountability and foil and the relationship between the board of directors, management and shareholders to help in find out the pa th and performance of the corporation (Hunger Wheelen, 2007, p. 18). The corporate governance system was designed to help oversee the decisions and best interest of the shareholders. The system should works thence The shareholders elect directors, who in turn hire management to make the chance(a) executive decisions on the owners behalf. The companys board of directors position is to oversee management and ensure that the shareholders interest is being served. Corporate governance focus is with promoting enterprise, to improve efficiency, and to guide disputes of interest which can force upon burdens on the personal line of credit. Ensuring that the clearness, and truth in a companys business can make contribution to improving the enterprise standards and popular governance. In brief, corporate governance is the system of controls to ensure that investors can sustain themselves that they will get their investment back.Depending on laws and other standard it might vary, but ge nerally Board of Director describes as bellowThose who set the overall path, vision and mission within the business.Those who make the decisions to hire and, or fire any top management member (Hunger Wheelen, 2007, p. 19)Those who oversee management and evaluate strategy.Those who have the shareholders best interest in mind.Those who review and venerate the use of company resources, as well as monitoring the dominance of the governance practices.Corporate Governance in U.K.Corporate governance is change in almost every country depending on a government issue of factors such(prenominal) as the economic development of the country, the strength of the legal system, the stability of the government but despite this the U.K is decidedly different from that of its neighbouring regions in the E.U. There is a unitary board of management and a broader shareholder bases as well as hardly any dual shares and no benefit structures. (Franks et al. 2004) An examination of the history and de velopment of corporate governance and legislation in the U.K may provide some answers to the considerable differences that have occurred in crease to many other European countries and worldwide.The U.K corporate governance practices have evolved from an business office perspective and the principal agent theory with a strong bias towards shareholder protection and shareholder rights. The protection of shareholders, in particular minority shareholders is covered by Company Law and is a major reason for the wide shareholder base characteristic of U.K listed companies.The major developments of a possible corporate governance system for the U.K came about due to a few notable high profile financial shits and public corporate collapses such as Maxwells Communication Corporation and Bank of Credit and Commerce transnational (BCCI). Robert Maxwell had been taking money out of the pension funds to incite his downwardly spiralling financial situations and managed to bypass auditors and shareholders alike. His uncurbed power made this possible. The BCCI scandal had a worldwide effect. The Bank was guilty of bribery, arms trafficking, money laundering, the sales agreement of nuclear technology, tax evasion, illegal immigration etc. Auditors were blamed again. subsequently these and various other scandals there appeared to be a lack of trustfulness in the ability of many U.K companies to accurately report on their financial situations. This led to an important committee being formed the Committee on the Financial Aspects of Corporate Governance.The report issued by the committee in celestial latitude 1992 is one the most influential codes on corporate governance and has been utilize and adapted by many other countries in the development of their corporate governance systems. Sir Adrian Cadbury was the Chairman of the Committee and so the report became known as the Cadbury Report. This report made many valuable recommendations on the composition and roles of t he board of directors as well as the non executive directors.Some of the recommendations given in the Cadbury Report were the separation of the Chairman and the CEO, the inclusion on non executive directors, uninterrupted and scheduled board meetings, directors access to advice, the length of appointments, the system of appointing non executive directors, disclosure of remuneration and the system of reporting and controls.All U.K registered companies who want to be listed must comply with the Codes of Best Practice recommended by the Cadbury Report. This comply or explicate system as opposed to statutory regulation is said to give the United Kingdom an advantage in that it doesnt unnecessarily constrain business practice and innovation. (Financial Reporting Council 2006)

Comparison of unusual administration methods of morphine

Comparison of unusual giving medication systems of morphia morphia is a unspecificly used analgesic. Its clinical use and the richly dependency factor ( morphia and heroin have proven to be the approximately addictive opiates) brought up the need to investigate the classic mellowways of disposal ( unwritten, rectal, iv, sc) and oppose them with somewhat non so well established highroads (nebulised, intrathecal, transdermal, sublingual etc). intromissionmorphia is a strong opioid derived from the opium poppy, Papaver somniferum1. It is used for the management of mute and blunt smart. It acts directly to central nervous system exhibiting a rapid time of action. Along with incommode relief, it take a leaks the sense of well being (euphoria). It flowerpot in addition produce a series of other central and marginal resolutions such(prenominal) as sedation, cough suppression, illness, constipation and strength flummox histamine release2. It is used during surgerie s for anaesthesia and as a pain reliever aft(prenominal) the operation. It is a do do do drugsss of natural selection for terminal c are and it is really helpful for pain management in cornerstonecer endurings3. morphia is open at several formulations and different drug administration send offs. The selection of the appropriate administration route is dependent on the extent of pain control required. For instance, parenteral morphia is used for neat monstrous pain, while oral exam morphia is used for the treatment of temporary pain. The location of the pain will also determine if it is necessary to apply topical preparations or not.Table 1 Pharmacokinetic Properties of three opioid analgesicsPharmacokinetic ParametersHalf lifeVolume of Distri scarcelyionClearanceMorphine (iv)2-3 hours3-5 litre/kg15 -20ml/min/kgFentanyl (iv)3.5-3.8 hours5-6 litre/kg21-29ml/min/kgDiamorphia(iv)2-3 legal proceeding25litre/kgUse morphia determineSource Clarkes analysis of drugs and poisons4M oreover, pharmacokinetic parameters such as bioavailability, half life and clearance and other characteristics of the drug (table 1) like situation effects, ADRs and interactions must be interpreted into account before choosing the appropriate drug route. Patients preference (or fear) for a particular proposition drug route and other psychosocial factors expertness also affect the choice of the formulation and patients compliance and finally medicines hard-hittingness.DiscussionOral routeRegarding oral route, morphia comes as a solution and as immediate or controlled (systained) release tablets and capsules(fig 2).Fig 2. Oral formulations of morphiaOral SuspensionMorphine solutions come in different strengths. Oral solutions support be appointed by writing the formula Morphine HCl 5mg and Chloroform water to 5ml but the proportion layabout be altered. Morphine Sulphate solutions (Oramorph) are forthcoming at 10mg/5ml and as concentrated solutions of 100mg/5ml3.Other excipi ents include ethanol (96%- morphine is slightly soluble in ethanol), corn syrup, sucrose, methyl parahydroxybenzoate (E218), propyl parahydroxybenzoate (E216) and purified water. ascribable to the high content of alcohol this drug is not recommended to alcohol misusers. radiation pattern adult process is 10-20mg all(prenominal) quad hours although when prescribed in alleviatory care dosage varies higher or lower according to the bitterness of the pain and kidney function respectively3.As this formulation is not readily mantled from GI tract, in order to produce same effects as iv venereal infection a 50%-100% increase in dose must be con steadred. Overdose jeopardize is high and can cause hypotension, respiratory depression and in some cases death. Naloxone which is an opiate antagonist is the outset line treatment in case of overdosing5.Tablets and CapsulesSolid dosage forms take for morphine in form of salt e.g Morphine Sulphate and Morphine hydrochlorate. Theses salts in the body will be available as morphine bases.Tablets are available in two preparations immediate release and circumscribed release. The short-circuit acting tablets come in 10mg, 20mg and 50mg3. They are given every 2-4 hours to control and stabilise breakthrough pain. These tablets are a way of find the amount of morphine needed to manage pain.Once the quantity of morphine is established the patient can take slow-release tablets and capsules. These formulations contain enough morphine to control pain for 12 or 24 hours. The starting dose varies and from 10-20mg every 12hours if the patient has not taken any other painkiller previously, to 20-30 mg every 12 hours in cases of replacement weak analgesics3. personal credit line only the dose can increase whereas the frequency must go forward the same i.e. every 12 hours. It can take up to 48 hours for the morphine to r distributively the required plasma levels meaning that it is important to be taken regularly otherwise they l ose their effectiveness5. If the patience attend pain between doses an additional dose must be given and the GP should decide if it is necessary to increase the daily dose.Oral morphine is a well established drug delivery rule however problems such as the first pass metabolism, the slow onset and the pretend of o.d. have raised questions on whether other novel administration routes can be used.IntravenousThis route is used only in hospitals and in managing emergency pain symptoms. The bolus administration provides almost instant onset with a short effect. Iv morphine is used when sc route is not tolerated. A popular application of this method is in Patient Controlled analgesia (PCA) where the opioid is delivered employ a Hospiral infusion device. The patient can control the morphine use of goods and services and establish an acceptable level of analgesia6. Morphine is available in 50 and 100ml vials with strength 1mg/ml3. It is used post operatively especially after transplant s surgeries and in the management of chronic pain of malignancy. Although this method is useful for the management of severe pain there are many drawbacks. First of all, most of the pumps are bulky and invasive. Their installation is complicated as they require mains attachment and the patient has limited mobility .There is a high risk of overdose therefore supervising is needed. Side effects such as hypotension and respiratory depression mogul develop while convulsions due to high dosage are believably to occur.fig3. PCA infusion device vs syringe driverSubcutaneousSubcutaneous method is an excellent alternative to oral administration method. It is safe and effective method which is widely used both in palliative care and severe pain management. It is used for patients that present conditions such as gastrointestinal disturbances including indigestion, palindromic social movement and obstruction5. A prime characteristic of the sc method is the syringe driver. The driver employ s simple syringes and bears a flow rate setting option ordinarily ml/hr which enables accurate dosing over a specific accomplishment of time. Unlike PCA infusion devices, it is battery powered, so patients mobility is not an issue (fig 3). The risk of overdose is lower compared to iv route as there is a constant stable administration schedule6. There is no need for endless strict supervision as the driver is easy to use.Often, the subcutaneous route can cause some skin site problems. Irritation might appear especially when there are high concentrations of morphine or when it is combined with other drugs which are not fully compatible3. This problem can be treated either by diluting the dose or by choosing alternative more compatible drugs.Also some patients might experience needle allergic reactions and action must be taken e.g produce an alternative Teflon cannula. Patients might feel discomfort, especially those who lack of subcutaneous tissue16. Sometimes, possible leakage of subcutaneous site might be observed. Finally, the sc method is not recommended for palliative care patients with acute vascular conditions.rectalThis drug administration route is quite a popular and is used for short term management of acute pain. Also in terminal genus Cancer patients modified release morphine sulphate is administered via this route6. Although the absorption rate varies for each individual, it is estimated that around 300-330 mg of morphine are absorbed rectally every four hours, indicating a sufficient analgesic effect.Studies have shown that for the patients who have never taken morphine, rectal morphine is more effective than the oral administered one5.Rectal morphine is available in the form of suppositories at different strengths (10, 15, 20 and 30 mg) 3. Prescribers must specify both the strength and the morphine salt (morphine hydrochloride or morphine sulphate) that suppositories should contain.Evidence shows two deaths15 after consequent doses of rectal morphine should raise awareness and the need of monitoring the dosing regimen and frequency.Rectal route is not avoiding completely the first pass metabolism therefore the bioavailability might be influenced.Non effected routesApart from the conventional drug routes mentioned before, it is necessary to assist into other not so popular ones such as the transmucosal, transdermal, sublingual, intrathecal and nebulised routes of administration and try to compare them.Transdermal- TransmucosalTransdermal route is a relatively painless method. The drug absorption is rapidly. Patches are easy to use and not quite expensive. Although this method is usually tolerated from the patients skin irritation and rashes might appear.Transdermal morphine is not popular as there are questions about the capability of this method. However, fentanyl another opioid is the drug of choice. More specifically, fentanyl patches are more effective in managing chronic pain compared to modified release oral mo rphine9. Also, transdermal fentanyl causes cut down constipation and drowsiness14.Another administration route which fentanyl is again preferred than morphine is the transmucosal route by a buccal tablet. The main reason is that fentanyl is a lipophilic drug while morphine has a limited lipid solubility. More specifically, when fentanyl is placed in saliva it is 80% non-ionizedand it usually takes 20-30 minutes for the analgesic effect to reach its peak14. Note transmucosal morphine is also available but the bioavailability is low and analgesic effect is not evidentiary.Sublingual routeThis route utilises soluble immediate release tablets and it is recommended to patients that have swallowing difficulties. Morphine enters into blood stream via sublingual mucosa. Investigations have shown that the absorption of morphine is the same (and in a few cases faster) compared with the oral route7. Same studies have shown that there is no significant difference in the extent and duration of analgesic effect when is compared with oral administered morphine3.Nebulised morphineNebulised morphine utilises the airways to deliver the drug into pulmonary circulation. It can be used for COPD patients in the management of acute thoracic pain11. Through this route, the effect of hepatic metabolism is avoided and a rapid absorption is noted. However, the plasma drug levels are unpredictable indicating the necessity of further clinical investigations. Studies showed that inhaled morphine was as effective as intravenous PCA morphine without causing strong sedating symptoms8. Although nebulised morphine is well accepted, patients who are not used to opioids might experience nausea and vomiting and in rare cases respiratory depression. Other common side effects include constipation and histamine induced broncho-constriction.Another drawback of nebulised morphine is the high cost of the equipment (nebuliser, injectable vials, etc). It is not a simple method and some patients might find it difficult to use the nebuliser. Studies show a wide range of bioavailability in subjects relating the bioavailability of the drug with the patients ability to use the nebuliser in the right way10.Epidural/intrathecalBoth epidural and intrathecal routes are used mostly in the hospital clinical environment. The bioavailability is high so spinal anaesthesia administered morphine can provide extended analgesic effect at lower doses (compared to the conventional drug routes)12. Although epidural and intrathecal morphine can relieve both acute and chronic pain studies suggest that these routes should be used only for pain which cannot be controlled by the classic established methods13. For instance, these routes are effective in managing lower body pain. Note that only 1% of the daily iv dose must be used intrathecally and only 10% epidurally5. An imbed infusion pump may be used to deliver intrathecal morphine at a continuous rate.A disadvantage of these methods is the high risk of infection and overdose as the staff must be learn and careful when dosing for breakthrough pains. Studies have reported a number of patients experiencing side effects such as sedation, dyspnoea, nausea and vomiting after spinal administration12.Spinal morphine is not usually preferred while diamorphine is the drug of choice due to its high solubility manner.ConclusionAs it was mentioned before, morphine can be administered via different routes. However, it is vital each time to guess the risk- benefit ratio for each method and choose the most effective and safe one. Moreover, before establishing unconventional methods such as nebulised and spinal morphine it is important to further investigate their suitability and ways to improve the drug delivery and minimise side effects. Finally, if it is necessary to choose other opiates (such as fentanyl and diamorphine), which might be more efficient than morphine.

Shakespeare Who killed Duncan

Shakespe ar Who killed DuncanMacbeth is now Thane of Glamis has he emerges from a businessy battle as a brave and fearless warrior. He is admired by umteen people as a great man. However, this proves not to be the case. Macbeth is one of Shakespe ars bloodiest tragedies. This play is a about control, aspiration, greed and eventually murder. These been the traits of Macbeth himself who ultimately wore the blood of king Duncan on his hands that fateful night, however thither were mevery contributory factors that was to influence his final decision.The play Macbeth is set in stifle and dreary Scotland, where power Duncan is the ultimate ruler. At the start of the play the Celts are in battle with the Norwegians. We are first introduced to Macbeth as a armed forces hero at his highest peak as he along with Banquo is locomote across the weather torn heath.Stumbling upon three witches Macbeth is told a prophecy in which he will eventually become Thane of Cawdor, and queen regnant of Scotland. Macbeth welcomes the idea of vastness and it is this which triggers the spiral of events in the story. However, the witches are simply responsible for the mere mental home of these ideas, merely, subconsciously implanting the railway yardght that Macbeth maybe able to control his own spate by saying All herald Macbeth, hail to thee Thane of Cawdor and All hail Macbeth that shalt be king there later on as a adore to Macbeth the witches plant a seed which continues to grow, eventually Causing Duncans death and eventually Macbeths own destruction.In the Elizabethan era witches were generally accepted as real. This period was very superstitious, fearing the power of witches the most. This stemmed from the supposed satanic beliefs of witches and their coalition with the Devil. Believing in the power of the super natural and religion, an Elizabethan listening would have believed the witches prophecies were going to become reality. This would in turn make them act on the gripping plot for the overall outcome of the play.We are then introduced to the citation of chick Macbeth in act one scene five. When she is reading a letter from Macbeth, dame Macbeths photoflash response to this, is the thought of killing magnate Duncan. Hie thee hither, that I may pour my invigorate into thine ear this shows she is nauseous for Macbeth to return so she can talk to him about the murder. However, she is worried that Macbeths feeling is too full o th milk of human kindness. She is alive(predicate) that her spouse is not without ambition, but without the illness should attend it. At this instant madam Macbeth is relishing the thought of eventually becoming Queen, with the prowess and vastness that this would bring. Though, she is clearly bear on that the temperament of Macbeth is too kind. Nevertheless with her awareness of this impuissance with the do-gooder of her powers of persuasion, her wavered confidence in Macbeth is soon reinstated. She kno ws that her economic consumption will soon bring success. gentlewoman Macbeths determination to be queen is quite unmistakable as makes reference to the raven who himself is hoarse and croaks the fatal entrance of Duncan. It is here that the audience would realise she is planning murder baron Duncan, she calls upon evil spirits to unsex me here abandoning all of her femininity, her direst cruelty is obvious when opposing her nature asking for it to take my milk for gall.Lady Macbeth appears to be brutal and distressing and thinks nothing of killing King Duncan, having no sense of what is right and wrong. Lady Macbeth believes that it is entirely moral to commit the act of murder, stating Wouldst thou have that which thou esteemst the ornament of life, and live a coward in thine own esteem, she impresses upon Macbeth that to not go through with the deed would be horrible to himself, and that he would be a coward in is own eyes. Here we see her manipulative techniques, by fashio ning Macbeth look weak, by questioning his manhood she hopes that Macbeth will respond by doing the opposite in post to maintain his strength in her eyes, and psychologically, in his own. In doing this her success is prevalent as Macbeth carries out her ruthless plan, careless(predicate) of his own conscience.After the murderous event, she, unlike Macbeth, is very calm and unemotional she asked Macbeth to return to the murder scene. However, his response ill go no more caused her to act alone. Lady Macbeth takes everything in her stride, raising well above any fear or doubt, and coldly states give me the daggers the sleeping and the dead are but as pictures tis the eye of childhood that fears a painted have words she then visits the murder scene returning the dagger to the Kings room and vigorously smears the grooms with blood of Duncan. This shows her strength and composure with no element of weakness.On Lady Macbeths return from the murder scene Macbeth is anxious and edgy. This is shown by Macbeths reaction to the bash Whence is that knocking. How isnt with me, when every noise appals me? On reflection of the killing of King Duncan Macbeth hallucinates and goes temporarily insane Methought I heard a voice utter Sleep no more Macbeth does murder sleep, the innocent sleep, sleep that knits up the ravelled sleave of care, the death of each days life, sore labours bath balm of excruciation minds, great Natures second course, chief nourisher in life feast. This shows the importance of sleep, and Macbeths perfect lack of it leading up too and subsequent to the murder of King Duncan. Unlike Macbeth, Lady Macbeth maintains her composure the day after the murder. However she is concerned that Macbeths weakness will soon prevail. We witness her anxiety when she urges her husband to be light hearted and merry.Lady Macbeths direct thoughts may make her appear short cold and ruthless, but is this really so? Lady Macbeth clearly takes travel in order to clear her conscience of the evil spirits to moderate up th access and passage to remorse in order to be relentless. I believe this was in order for her conscience to exit her to act in such an unremorseful way.The phenomenal strength of Lady Macbeth is invigorated for the occasion and her heartless abilities are proved through her situation attention to detail regarding the murder. But still, her moral conscience triumphed as lady Macbeth eventually revealed this when she comments Had he not resembled my father as he slept, I had donet In conclusion after carefully considering the mitigating factors leading up to the tragical event Lady Macbeth played a large part in the precipitated murder of King Duncan. However, Ultimately It was Macbeth who was responsible for his death after sercoming to her manipulation by committing the eventual act. Unfortunately Macbeths downfall was caused by his greed after allowing his ambition to control his destiny. I strongly believe the witches can no t be blamed for Macbeths murderous behaviour themselves. The witches simply anticipated alternatively than initiated Macbeths actions. I am of the belief that with the influence of lady Macbeth in addition to his clear personal ambition Macbeth would have, in time, still murdered King Duncan. Macbeth was himself a callus individual who wouldnt let anyone or anything stand his way. It is in the end, each individuals decision to fall for the temptation, or to be strong comme il faut to resist their captivation.

Antidepressants for Postnatal Depression

Antidepressants for post split upum mental pictureAntidepressants ar they a safe and launchive alternative for the intervention of post pa mappingum falloff?This refreshen valueed the curtilage concerning the strength and precaution of antidepressants in the existenceagement of postpartum first. This would facilitate at shield-establish clinical decisions in the manipulation of perseverings. selective in sortation was sourced from several electronic Athens- base and free databases c oering the psycho-biomedical and nursing belles-lettres.Studies found everyplacewhelm randomize clinical trials, miscue- and cohort- potencyled studies, questionnaire surveys, and qualitative/exploratory look for. antecedent critical round offs were alike measure outd. Outcomes from over 1200 m early(a)s, m new(prenominal)-infant pairings, or infants, subject to antidepressants were con human facered. Antidepressants appear to signifi faecal mattertly alleviate depressive symp toms. Further to a greater extent(prenominal)(prenominal), the account posture personal do ar customaryly propitious and clinically in satisfying. However, methodological and analytic flaws controvert definitive inferences.M any(prenominal) studies fail to account for important covariates that whitethorn explain set up attrisolelyed to antidepressants. moreover, nearly studies fail to account for interactions between antidepressants and uncomplaining characteristics, which whitethorn tell more consummate(a) indecorous groom. Additionally, there is a paucity of belles-lettres on long-term tack togetheruate. Finally, a lack of disarrange clinical trials precludes inferences of causativeity. given(p) these constraints it is recommended that antidepressants argon kind occasiond as a determination resort, and long-sufferings ar nigh monitored to commit un evaluate side effectuate, or retrieval induced by covariates quite than antidepressants.Chapte r OneIntroduction, Rationale, AIMSIntroductionAccording to Beckford-ball (2000) postnatal clinical impression (PND) fails to curl public attention beca give it is associated with a positive re hand vaginal birth in sentence the recount that a sizeable majority of women lie with this phenomenon afterward(prenominal) delivering their treat (RCP , 2004). Nevertheless postnatal mental picture, if left untreated, drive out eat up adverse effects for mother- pincer relationship and infant development (Green, 1995).This brief re projects evidence concerning the caoutchouc and forcefulness of antidepressants for treating postnatal nonion. It is argued that while antidepressants whitethorn alleviate depressive symptoms, with gracious side effects, conglome run methodological and analytic constraints in the publications negate conclusive inferences on the subject.AntidepressantsAccording to the RCP antidepressants are doses developed in the fifties for treating sym ptoms of slump (RCP, 2006).They break down by stimulating neurotransmitters in the brain. troika primary(prenominal) types of antidepressants are undertake 1. Tricyclics (TCAs) amitriptyline, imipramine, nortriptyline. 2. Selective Serotonin reuptake Inhibitors (selective-serotonin reuptake inhibitors) 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 sideline three months of word 50% to 65%of bulk given an antidepressant show improvements in vagary, likend with 25% to 30% of raft administered a hindquartersbo. Thus, even after accounting for placebo effects, antidepressants lifelessness facilitate gain ground recovery from depressive symptoms. TCAs are oecumenicly older than selective-serotonin reuptake inhibitors and are considered to produce more side effect s, e fussyly if there is an overdose.However, all quaternion classes of antidepressants are considered to give birth by-products, much(prenominal) as mellow blood wring, fretfulness, indigestion, teetotal mouth, look tremor, and sleepiness. close to of the adverse effects are considered mild and expected to dissipate after few weeks.The RCP cites evidence of withdrawal symptoms in infants soon after birth, especially with paroxetine (RCP, 2006). Babies can besides receive a thin concentration of antidepressants via breastfeeding (Kohen,2005), albeit the seek of pathology is considered small referable to the rapid development of kidneys and livers in infants. Overall, engross of antidepressants during breastfeeding is non discouraged. Some pregnant women suffer a riposte of depressive symptoms, and therefore may consume to take antidepressants continually.The theme Institute for clinical Excellence (NICE, 2004) has promulgated guidelines for the sermon of depressio n. However, there is no special stress on motherhood-related depression. prenatal and postnatal guidelines are due to be create by 2007 (Green, 2005).postpartum DepressionAccording to the RCP (2004) postnatal depression (PND) is what happens when you flex downhearted after having a baby (p.1). It is quite common, affecting circa 10% of in the buffly delivered mothers, and can last for several months or longer if untreated. Symptoms include tang downhearted (unhappy, low, wretched, with symptoms becoming worse at fact metre of the day), irritable(heightened sensitivity, especially to benign comments by others),tiredness, sleeplessness (late retirements, early rises), and lack of longing and reside in sexual intercourse. Many women may feel they are unable to bed with the new situation, or even get down anxiety and detachment towards the infant. unhomogeneous causes of PND put up been identified including a previous register of depression, non having a supportive pa rtner, having a sick infant or premature delivery, losing unrivalleds own mother as a child, and stressful purport events (e.g. bereavement, divorce, financial problems) within a short time scale. PND has also been associated with hormonal changes.PND appears to progress by means of several stages (Beckford-Ball, 2000 Green, 2005)1. Postpartum colour 2. Postnatal depression 3. puerperal psychosis.Postpartum megrims is usually a transient phase angle 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 stipulate is easily treated use horm unmatched reserve therapy.Postnatal depression is less frequent, and emerges as a deep and lengthen sadness which is a great deal more intense and persistent than postpartum blue and its symptoms rarely patch up without assistant (p.126).Many mothers may feel insecure, i ncompetent, irritable, guilty (about feeling sad following a happy event), charge changes, insomnia/hypersomnia, psychomotor mental retardation/agitation, tiredness, and loss of interest in activities. This condition often results in hospitalisation and treatment with antidepressants and cognitive-conductal counseling.Puerperal psychosis is a severe mood disorder typified by delusions and hallucinations. This condition is considered a psychiatric emergency, necessitating admission to a psychiatric grounding and treatment with antidepressants and other doses.RationaleDespite clear guidelines regarding the use of antidepressants during motherhood it is essential to appraise live literature on the topic, for several reasons1. trammel ground of existing reviews. 2. appellation of gaps and inconsistencies in the literature 3. stop of flow value claims and guidelines, for example by the RCP, regarding the management of postnatal depression.Limited scope preliminary literatur e reviews are considered in this brief (see Chapter 3). Most reviews are particular in scope mainly because they focus on studies utilize a particular research methodology(e.g. stall 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 penetration into electric la essay literature.Identification of gaps and inconsistenciesPrevious reviews on the topic pass sidle uped problems that need to be communicate in future research. However each review is different and new research findings continually emerge that may down implications for previous reviews. For example, ag ane reviews feed found little evidence of malformations resulting from selective-serotonin reuptake inhibitor use (e.g. Booth et al, 2005). However, new concerns are starting to emerge regarding miscellaneous analytic and methodologica l constraints that negate conclusive inferences about the synthetic rubber of selective-serotonin reuptake inhibitors.Verification of current claimsThe RCP publishes an teaching guide for the use of antidepressants. Various claims are make regarding safety and skill of use during/after pregnancy, consistent with NICE(2004) standards. period most assertions are based on research evidence there is a need for on-going reviews that lavishlylight recent findings and consider their implications for existing guidelines.Some of the bring up pronouncements and guidelines are as follows1. People who take antidepressants show a evidentiary 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 trump to carry on taking antidepressants while breastfeeding, since wholly minute amounts entrust be transferred to the baby. Livers and kidneys develop rapidly in babies provided a few weeks old, helping to breakdown and filter antidepressants in the bloodstream. bearingThe 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 examination search of four-fold databases including HIGHWIRE Press, ACADEMIC SEARCH PREMIER ( opening through EBSCO databases), Psych INFO, INTERNURSE, and the British MEDICAL daybook database. The Internet was also searched with fury on consort-reviewed publish diary articles. name words included antidepressants, depression, and postnatal depression. there were no problems of doorway all the databases reviewed are available to the general public through university library resour ces 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 floors, and dissertations, make in numerous countries. As a form of psychopathology, PND is comprehensively turn to. INTERNURSE provides access specifically to the nursing literature and holds may observe journals (e.g. British diary of Nursing, Nurse Prescribing, Practice Nursing, and the International Journal of palliative Nursing).HIGHWIRE Press is bingle of the devil largest archives of free full-text science databases available, providing access to thousands of psych biomedical journal articles and books. ACADEMIC SEARCH PREMIER incorpo pass judgment 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 non provide commensurate access to full-text articles.Only studies that satisfied the following criteria were legal to be reviewed1. observational studies victimisation every qualitative or vicenary methods. Thus, this included case studies, questionnaire surveys, retrospective/prospective designs, and randomised controlled trials(RCT).2. Review articles and meta- synopsis, including Cochrane reviews.3. direction on the effects of antidepressants on mother and/or child, and with or without breast-feeding.4. concentrate on postnatal depression, at any stage (i.e. postpartum blues, depression, and puerperal psychosis Beckford-Ball, 2000).5. focalise 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 roughly 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 memorize. However, someone studies are bad constrained in scope and will in the long run provide a snap-shot or localised insight on the subject. Moreover, scientific knowledge advances from the aggregation 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 soul studies assume greater importance.Depression as a topic has been severely researched. Numerous studies have been published on antidepressants and PND. The numerosity of published literature reviews on antidepressants/PND at attempts to the abundance of empirical evidence on th e topic. Thus, attempting to establish the safety and efficacy of antidepressants on the basis of a hotshot sphere would lock away require an understanding of what has been done before and current knowledge on the topic. Otherwise the researcher is in danger of entirely reinventing the wheel. Thus, proper scientific protocol dictates that the researcher first begins by reviewing the literature, in order to induce 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 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 antidepres sants, given that medical prognosis for PND is often good, despite concerns about over-sedation, and other considerations.The strike aimed to establish the best treatment frond. The antidepressant of interest was the SSRI, fluoxetine. Participants were women identified at an urban wellness district(Manchester) as being depressed 6-8 weeks post childbirth. They accurate the EPDS , and those with sufficiently high piles were interviewed using a revised clinical schedule, to identify cases of pregnant psychiatric depression. Women with a prior report of depression, sum abuse, severe unsoundness that required hospitalisation, or breastfeeding, were excluded.Participants were randomly charge to one of four observational conditions fluoxetine, placebo, one counselling session, and six counselling sessions. body fluid 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 epitome of variance for repeated measures (to account for the three-fold outcome uncertains).Overall, 188 substantiate cases of PND were identified, from a sample of2978 women suitable to participate.Of these, 87 took part in the clinical trial. Results revealed real improvements in all four treatment sorts. Fluoxetine produced check 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 causalitys conclude this dissect 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 dissemble of an antidepressant. However, the analysis failed to control for potential confounding variables.While Appleby et al (1997) took stairs 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 companionable support, marital relationship, stressful life events, side-effect profile, history of drug compliance, patient gustation Green, 2005) to demonstrate the statistical significance of these variables, and the unique voice of SSRI treatment after autocratic for covariates. Thus, analysis of covariance would have been a more separate test.Nolan et al (1997) assessed the effect of TCA and SSRI drugs on feta neurodevelopment. The cultivation 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 antidep ressants. Outcomes measures comprised world(prenominal) IQ and words 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 concourse 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 say assessing the effects of TCA and fluoxetine use throughout pregnancy on child development.Three multitudes of mother-child pairs were recruited. The first deuce hosts were drawn from the Mothers Program, a scheme that provides support to women crucifixion from major depression. all(a) women recruited from this programme had received counselling under the scheme, with either TCA Rossi (fluoxetine) treatment, w hich had been maintained throughout the duration of the pregnancy.A comparison congregation was also recruited that comprised women with no history of psychopathology, depression (based on the Centre for epidemiologic Studies Depression Scale CES-D), picture to chemical or radiation pollution, or severe health problems in all likelihood to affect fatal development. This sort out was randomly selected from among visitors to the authors clinic. Women who had cease the use of antidepressants after belief or during the pregnancy were not pensionable to participate.Women were also excluded from the comparison classify based on the same criteria apply 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- hold Achenbach Child Behaviour Checklist), and follow-up interrogation of them other (Wechsler bad Intelligence Scale, and other measures). A one-way analysis of variance was utilize to compare outcome measures crossways the three groups. correlational and degeneration tests were apply 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, word picture to tricyclic antidepressants or fluoxetine throughout the parental quality peak does not appear to adversely affect cognition, language development, or the temperament of preschool and early-school children. Although regression was apply to account for the contribution of confounding circumstanceors, such as vocal comprehension and expressive language, the variance explained by these variables was not in fact partial led out before test for group differences.This would have required a multivariate analysis of covariance in which adjustments for covariates are build 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 right away 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 field of honor was followed up with another RCT (Wisn er 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 touch on of antidepressants in women who have previously had a depressive episode, and wherefore 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 rendering of major depression. Women with other forms of psychopathology (e.g. psychosis, or bipolar disorder) were excluded. Participants were randomly designate to a treatment (sertraline) or placebo group. The drug was administered at present after birth, spring with a 50mg/day dose, which was later dropped to 25mg/day to minimize 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.Re occurrences 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(prenominal) women had adhered to the treatment regime, so minimising the confounded effect of on-compliance. There was also a significant group difference in time to reoccurrence, with first reoccurrence start out much foregoing 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 inform 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 hardship to control for unwrap background variables, such as previous and recent history of psychopathology, and drug effect expectations. For example, remain symptoms of a dista nt depressive episode may help precipitate a quicker reoccurrence.Figure 2 Rate of proceeds of postpartum depression in placebo and SSRI women (Wisner et al, 2004)Oberlander et al (2005) tested the effect of SSRI mental picture on bio behavioural responses to acute procedural disquiet in new-born babies at2 months of age. Previous research has suggested altered behavioural and physiological reactions to a routine wrenching event in infants, after prenatal film 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. accustomed that SSRIs work by inhibiting the reuptake of serotonin(5-hydroxytrypamine 5HT, a neurotransmitter that regulates cardiovascular function and hurt signals in the growing brain), and given that SSRIs easily pass through the placenta, it is mathematical that regions of the brain associated with pain responsiveness may be affected. Participa nts were recruited from a cohort of mothers and their infants during pregnancy, as part of a longitudinal moot of prenatal practice of medicine 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 utilise as a measure of pain reactivity in infants), and pharmacologic (analysis of blood and breast milk samples) data was collected.Results showed stricken facial reactions in infants exposed to prenatal SSRI. Altered pain reactivity was observed in both prenatal and postnatal exposed infants, suggesting tolerate neuro behavioural SSRI effects that e xtend beyond the new-born phase. Oberlander et alls(2005) report 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 uphold effects of SSRIs.Marcus et al (2005) screened prenatal depression in pregnant women be an obstetrics clinic. The study aimed to assess the rates faint-depressant use and its association with depression, careful byte Centre for Epidemiological Studies Depression Scale (CES-D).Overall, 390 women who had used antidepressants within 2 years of conception were screened. Average age was 28.6 years, and most women were married and egg white (73%).Screening took place at around 24gestation weeks. Data was collected regarding the use of antidepressants during the past two years, and discontinu ed use following pregnancy, in appurtenance to the CES-D data. The standard CES-Duct-off of 16 was used to establish the presence of depressive symptomatology.A t-Test was used to compare two groups women who reported they stopped using anti-depressants and hence were not currently on medical specialty (n=248) and women who continued to use antidepressants during pregnancy (n=68). The hooked/outcome variable was total CES-Scores. Chi-square was also used to assess use/non-use of antidepressant medicine 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). notice differences are not significant.The authors attributed the vigor 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 disco ntinued use). This study was unique because it assessed antidepressant use around the time of conception.However, the findings are compromised by several analytic constraints. Firstly, these of a t-Test is questionable. This test makes no provision for controlling for covariates (i.e. important background variables, such as patient preference, compliance history, side-effect profile, social support, quality of marital relationship, prior history depression)that may confound significant group differences, although this concerns less important given the abortive results.A more serious problem is the theory 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 true differences in CES-Scores. The authors do not report Levine test results, which would have addressed the homogene ity 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 microscopic 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 undecipherable 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 chastening Kostass, 2002 Hendricks, 2003 Bennett et al, 2004 Cohen, 2005Marcus et al, 2005) to comprehensive and arrogant 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 subjective identify and weigh the risks against the benefits in order to make an informed choice as to whether or not to use the drugs. callable 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. quadruplet cohort-controlled and 5 prospective studies were found which evaluated the impact of SSRI moving-picture show. 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 leaning for fluoxetine- and tricycli c-exposed women to miscarry compared with controls. However, this effect was not significant and hence may only if 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 preponderance 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 preponderance of stillbirth, prematurity, mean birth weight and gestational age. reason 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 lengthen 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 Postnatal 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.Many studies fail to account for important covariates that may explain effects attributed to antidepressants. Furthermore, most studies fail to account for interactions between antidepressants and patient characteristics, which may reveal more severe adverse effects. Additionally, there is a paucity of literature on long-term effects. Finally, a lack of ra ndomised 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 postnatal depression, if left untreated, can have adverse effects for mother-child relationship and infant development (Green, 1995).This brief reviews evidence concerning the safety and effectiveness of antidepressants for treating postnatal depression. It is argued that while antidepressants may alleviate depressive symptoms, with benign side effects, vario us 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 Inhibitors (MAOIs) tranylcypromine, moclobemide, phenelzine.The RCP posits that following three months of treatment 50% to 65%of people given an antidepressant show improvements in mood, compared with 25% to 30% of people administered a placebo. Thus, even after accounting for placebo effects, antidepressants still facilitate further recovery from depressiv e 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 guid elines 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 comments by others),tiredness, sleeplessness (late retirements, early rises), and lack of appetite and interest in sexual intercourse. Many women may feel they are unable to cope with the new situation, or even experience anxiety and detachment towards the infant.Various causes of PND have been identified including a previous history of depression, not havin g 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 appraise 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 (s ee 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 implications for previous reviews. For example, past reviews have found little evidence of malformations resulting from SSRI use (e.g. Booth et al, 2005). However, new concerns are starting to emerge regarding various analytic and methodological constraints that negate conclusive inferences about the safety of SSRIs.Verification of current claimsThe RCP publ ishes 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 onl y 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 postnatal depression. There were no problems of access all the databases reviewed are available to the general public through university library resources and/or Athens protected resources. These particular databases were chosen because of their emphasis on psychological, biomedical, and practice-based literature, and easier access to full-text files.For examp le, Psych INFO contains more than1,500,000 references to journal articles, books, technical reports, and dissertations, published in numerous countries. As a form of psychopathology, PND is comprehensively addressed. INTERNURSE provides access specifically to the nursing literature and incorporates may key journals (e.g. British Journal of Nursing, Nurse Prescribing, Practice Nursing, and the International Journal of Palliative Nursing).HIGHWIRE Press is one of the two largest archives of free full-text science databases available, providing access to thousands of psych biomedical journal articles and books. ACADEMIC SEARCH PREMIER incorporates over4000 scholarly journals and 3100 peer review articles. These databases were preferred to others such as SCIENCE DIRECT, have a more general emphasis on scientific (rather than clinical, medical) literature, or not provide sufficient access to full-text articles.Only studies that satisfied the following criteria were eligible to be reviewe d1. 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 published literature reviews on antidepressants/PND attests to the abundance of empirical evidence on the topic. Thus, attempting to establish the safety and efficacy of antidepressants on the basis of a single study would still require an understanding of what has been done before and current knowledge on the topic. Otherwise the researcher is in danger of m erely 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 this area. Appleby et al (1997) question the clinical benefits of using antidepressants, given that prognosis for PND is often good, despite concerns about over-sedation, and other considerations.The study aimed to establish the optimal treatment frond. The antidepressant of interest was the SSRI, fluoxetine. Participants were women identified at an urban health district(Manchester) as being depressed 6-8 weeks post childbirth. They completed the EPDS , and those with sufficiently high scores were interviewed using a revised clinical schedule, to identify cases of significant psychiatric depression. Women with a prior history of depression, substance abuse, severe illness that required hospitalisation, or breastfeeding, were excluded.Participants were randomly assigned to one of four experimental conditions fluoxetine, placebo, one counselling session, and six counselling sessions. Mood assessments took place at 1, 4, and 12 weeks post-intervention, using the revised interview schedule, EPDS, and Hamilton depression scale. Data was analysed using analysis of variance for repeated measures (to account for the multiple outcome variables).Overall, 188 verified cases of PND were identified, from a sample of2978 women eligible to participate.Of these, 87 took part in the clinical trial. Results revealed significant improvements in all fou r 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 informat ion 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 differen ces in any of the outcome variables, suggesting that in utero ingestion of either TCAs or fluoxetine does not impair cognitive, linguistic, or behavioural development in infants. Null man et al (2002) conducted follow-up prospective controlled study assessing the effects of TCA and fluoxetine use throughout pregnancy on child development.Three groups of mother-child pairs were recruited. The first two groups were drawn from the Mothers Program, a scheme that provides support to women suffering from major depression. All women recruited from this programme had received counselling under the scheme, with either TCA Rossi (fluoxetine) treatment, which had been maintained throughout the duration of the pregnancy.A comparison group was also recruited that comprised women with no history of psychopathology, depression (based on the Centre for Epidemiological Studies Depression Scale CES-D), exposure to chemical or radiation pollution, or severe health problems likely to affect fatal devel opment. 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 measures). A one-way analysis of variance was used to compare outcome measures across the three groups. Correlational and regression tests were used to assess the contribution of confounding variables.Results revealed no group differences in childs global IQ, language development, or behaviour (see Figure 1). The authors concluded, Exposure to tricyclic ant idepressants 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 random ised control trial to assess the effect of nortriptyline on the rate of reoccurrence of postpartum depression in non-depressed women who had previously had at least one depressive episode. Women were randomly exposed tonortriptyline or a placebo immediately after childbirth. Outcome data was collected over a 5-month period using the Hamilton Rating Scale for Depression, and Research Diagnostic Criteria for depression.No group differences emerged, suggesting that nortriptyline was no more effective than a placebo in treating PND. This study was followed up with another RCT (Wisner et al, 2004), this time evaluating the effect of sertraline on the rate of and time to reoccurrence of postpartum depression. They highlighted a paucity of clinical trials on the impact of antidepressants in women who have previously had a depressive episode, and hence may be prone to experience a reoccurrence.Participants were pregnant women with gestation periods of 9 months or less, and at least one epis ode 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, and1/14 women in the treatment condition, translating into a 0.43difference in reoccurrence rates. All women had adhered to the treatment regime, thus minimising the confounded effect of on-compliance. There was also a significant group difference in time to reoccurrence, with first reoccurrence beginning much earlier for the placebo group (at 5 weeks, fo llowed by more reoccurrences) compared with the treatment group (at 17 weeks, followed by more reoccurrences).However, the treatment group reported more side effects (e.g. Dizziness, drowsiness). This RCT clearly demonstrates the effectiveness of an SSRI in preventing the reoccurrence of postpartum depression, albeit the conclusiveness of these findings is constrained by the failure to control for key background variables, such as previous and recent history of psychopathology, and drug effect expectations. For example, lingering symptoms of a distant depressive episode may help precipitate a quicker reoccurrence.Figure 2 Rate of recurrence of postpartum depression in placebo and SSRI women (Wisner et al, 2004)Oberlander et al (2005) tested the effect of SSRI exposure on bio behavioural responses to acute procedural pain in new-born babies at2 months of age. Previous research has suggested altered behavioural and physiological reactions to a routine painful event in infants, after p renatal 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 wome n attending an obstetrics clinic. The study aimed to assess the rates faint-depressant use and its association with depression, measured byte Centre for Epidemiological Studies Depression Scale (CES-D).Overall, 390 women who had used antidepressants within two years of conception were screened. Average age was 28.6 years, and most women were married and Caucasian (73%).Screening took place at around 24gestation weeks. Data was collected regarding the use of antidepressants during the past two years, and discontinued use following pregnancy, in addition to the CES-D data. The standard CES-Duct-off of 16 was used to establish the presence of depressive symptomatology.A t-Test was used to compare two groups women who reported they stopped using anti-depressants and hence were not currently on medication (n=248) and women who continued to use antidepressants during pregnancy (n=68). The dependent/outcome variable was total CES-Scores. Chi-square was also used to assess use/non-use of an tidepressant medication and CES-D groupings (i.e. Figure 3 CES-D data for women who did and those who did not use antidepressants during pregnancy (Marcus et al, 2005). Observed differences are not significant.The authors attributed the null results to poor treatment adherence, and inadequate prescribing/monitoring. Furthermore, they suggested that group differences might have been more pronounced if the study focused on unmediated women (i.e. those who had not used antidepressants at all, rather discontinued use). This study was unique because it assessed antidepressant use around the time of conception.However, the findings are compromised by several analytic constraints. Firstly, these of a t-Test is questionable. This test makes no provision for controlling for covariates (i.e. important background variables, such as patient preference, compliance history, side-effect profile, social support, quality of marital relationship, prior history depression)that may confound significant group differences, although this concerns less important given the null results.A more serious problem is the possibility that certain assumptions which underlie use of the t-Test were violated, notably homogeneity of variance. The huge disparity in group sizes (268 versus 68) hugely increases the possibility of significant differences in group variances, which in turn would obscure reliable differences in CES-Scores. The authors do not report Levine test results, which would have addressed the homogeneity issue. Perhaps a non-parametric test (e.g. Mann-Whitney) may have been more appropriate.Furthermore, it is not clear why the authors conducted a chi-square test Collapsing the CES-Scores into a dichotomy reduces the quality of the data because it obscures subtle differences between scores. Overall, the chi-square analyses amounted to a less precise duplication of the t-Test results Finally, this study was entirely based on 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 identify and weigh the risks against the benefits in order to make an informed choice as to whether or not to use the drugs. Due to the paucity of randomised controlled trials on the topic, the review focused on evidence obtained from cohort/case-controlled studies, patient surveys, retrospective studies, and anecdotal reports.Electronic databases search ed 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 prevalence of minor anomalies that have little or no clinical importance. Furthermore late exposure to fluoxetine seemed to increase the rates of admission to special care nurseries and impaired fatal development.However, these findings were inconclusive due to prior group differences on previous psychotropic drug use, and failure to control for depression levels. Still other research suggests no effect of SSRIs (sertraline) on the prevalence of stillbirth, prematurity, mean birth weight and gestational age. Evidence suggests no statistically significant differences between SSRI exposed and control groups on IQ, language development, height, and head circumference.Of the prospective studies reviewed three assessed paroxetine, and fluoxetine, and two tested sertraline. All studies reported no significant increase in the rate of malformations and spontaneous abortion, although there was some evidence of lower birth weight given protracted use of antidepressants.Goldstein and Sun dell (1999) found one study, which showed that fluoxetine exposure during the first trimester di d not increase the risk of malformations

Examples Of Some Best Leaders And Managers Commerce Essay

Examples Of Some Best Leaders And Managers Commerce EssayLeadership and worry argon oneness of the almost discussed topics in business corporates and organizations. It is highly marvelous to switch on some(prenominal) media (radio, inter take in, etc.) and non run into a compute of topics that do non link fundament to loss leading and managers. By definition, the dickens carcasss argon not the a kindred(p) however, they need to be utilized complementarily to exit to one general conclusion and any effort to separate the 2 will cause to a greater extent than lineatic issues than it will solve. In exploit to point out the difference, this report will address different aras of both leading and oversight, such(prenominal) as different characteristics of a leader, theories of lead, management and its skills, and roughly examples of strong managers.There whitethorn be roughly intersections, exactly the meaty difference between the 2 systems is that leading are born and managers are made. Though lead comes as a natural talent this is not plenty to define a unspoilty qualified leader as in that respect moldinessiness be a constant im resurrectment at every step of their career by investing tons of efforts and competency into their work to truly accomplish the definitions of lead qualities. On the other pay, in a nutshell managers are problem solvers depending on the crusadeableness and control and they circularise what has been innovated by leaders.Leadership and ManagementIt has become quite a common practice to sort out between leadership and management. The almost signifi brush asidet dowry off every last(predicate) these differentiations is that they are all orientated towards change. This idea is substantially outlined by John Kotter in his book who came to a mop up that management is about heading with tortuousity whilst leadership, by contrast, is about coping with change (John Kotter, 1990, p104). He stated t hat steady- melt downage management brings about a degree of order and consistency to organizational processes and goals, whilst leadership is required for closely change.The differentiation of leadership from management as outlined by Kotter ostensibly inspires a change in emphasis from the moderately inflexible, administrative processes characterized as management to the more fast and strategic processes categorized as leadership, hitherto even he concludes that both are of equal magnificence for the legal running of an organization, Leadership is different from management, exactly when not for the effort most people think. Leadership isnt mystical and mysterious. It has no topic to do with having personal magnetism or other exotic nature traits. Its not the province of a chosen few. Nor is leadership necessarily give out than management or a replacement for it rather, leadership and management are two distinctive and completing activities. Both are necessary for winner in an increasingly complex and volatile business surround. (Kotter, 1990, p103).Even though there are a quite number of business writers such as John Kotter and his multiplication who argue that there is a difference between leadership and management, however, these arguments cannot prove beyond reasonable doubt, especially when we put practice into friendship, wherefore approximately people doubt as to whether they are really quite as separate as this in practice. Firstly, there has been an increment in the rejection to the guidance in which studies tend to disparage management as a system that is tedious and uninspiring. Gosling and Murphy (2004) propose that upholding a brain of steadiness during quantify of rapid change is a key to successful leadership. Thus the leader must safeguard that systems and structures remain in place whose purpose is to crock up workers a feel of security and a sense of balance, without which it would be solid to maintain levels of pauperization, commitment, trust and psychological wellbeing.Secondly, research has sh hold that the two systems are distant from being separate thus the practices labeled as management and leadership are an innate fragment of the same task. From the exhaustive interpretations of what managers really do, Mintzberg (1973, 1975) place 10 key roles, and among the roles leadership is one of them. He further came to a conclusion that far from being separate and different from management, leadership is just now one dimension of a multidimensional management role. The most unmanageable thing and which causes confusion that are derived from comparing leadership and management is the regularity acting in which they are often charted to different singles. Therefore, we often refer to managers and leaders as if they were different and incompatible people we look at leaders as individuals who respond to rapid changes quite easily thus dynamic, charismatic individuals with the capacity to inspire others, whilst managers are seen as administrators who just focus on the accredited task. such(prenominal) an interpretation, however, does not concur well with an individual who is experienced as a manager. People are generally employed into management, alternating(a)ly of leadership positions, and are expected to complete a pile of tasks extending from terrene planning and implementation, to coarseer-term strategic planning. None of these are done in isolation, and throughout, it is essential to work alongside other people to motivate and inspire them, scarce also to know when to relinquish the lead and take a back seat. Most of us urinate become so enamored of leadership that management has been pushed into the background. Nobody aspires to being a good manager any longer everybody wants to be a wide leader. But the separation of management from leadership is dangerous. Just as management without leadership encourages an uninspired manner, which deadens activi ties, leadership without management encourages a disconnected room, which promotes hubris. And we all know the destructive power of hubris in organizations. (Gosling and Mintzberg, 2003).Leadership TheoriesEven though individuals who are practically complicated active within the leadership field, they see practice being different from theories, solely they are inseparably related. Traditional leadership theories were more fixated on what qualities differentiate between leaders and followers, while contemporary theories looked at other variables such as blank spaceal factors and skill levels.Both of these types of theories of leadership have an impact the current practice, education and policy and offer a useful blow overline for the survival of the fittest and development of leaders in other words theories are as well good to be practical.I will discuss some of the most prominent leadership theories, which offer a valuable context for the consideration of wider issues about defining leadership capabilities and development overturees.Leadership TraitsFor a long time it was presumed that it would be feasible to recognize and separate a moderate tempered of traits, which can then be used to employ individuals in the positions of leadership. These qualities include but not limited to -strong drive for responsibility, -focus on completing the task, -vigor and persistence in pursuit of goals, -originality in problem-solving, -drive to exercise initiative in social settings, -self-confidence, -sense of personal identity, -willingness to harmonize consequences of decisions and actions, -readiness to adsorb interpersonal stress, -willingness to tolerate foiling and delay, - efficiency to invite the behavior of others, and -capacity to structure social systems to the purpose in hand. This method was strongly based on the great man theory that voiceless on how umpteen records occupy and maintained positions where they have the capacity to influence. The guessing was that these individuals were born to be leaders and would grow by quality of their personality alone. Ralph Stogdill (1974) carried out a study to extensively revise the traits, and concluded that some qualities appeared more often than others. Other studies were carried out as well (e.g. Bird, 1940 Stewart, 1963) but did not identify the same set of traits. Since then the list has been growing, therefore it is now widely accredited that no such decisive set of traits will ever be identified.Leadership styles and behaviorAn approach which is an alternative to the traits approach was to look at what leaders actually do sooner of just looking at their funda psychogenic characteristics. Attention in this approach came about by the work of Douglas McGregor (1960), who suggested that leadership and management style is moved(p) by the distributively individuals views about human nature. He briefly contrasted two theories of managers which he called supposition X and Theor y Y. Theory X managers somewhat look at human nature negatively, thus trusting that the sightly employee has an in-born dislike of and will not do the job at hand if it is possible. Managers who perceive in this view believe that employees need to be nigh supervised and controlled to make sure that tasks are successfully completed. Theory Y managers assumes employees may be striving and self-motivated and exercise self-control. Expenditure of physical and mental effort in work is as natural as flow or rest, and that the average human being, under proper conditions, learns not only to accept but to seek responsibility. Such leaders will determination to enhance their employees capacity to exercise a high level of imagination, cleverness, and creativeness in the answer to organizational problems. It can be understood that leaders holding various(a) assumptions will show different methods to leadership Theory X leaders preferring an autocratic style and Theory Y leaders preferri ng a graphic symbolicipative style.Contingency TheoriesThese theories concentrates on particular factors associated to a specific environment that might govern which particular leadership style will most suitably be fit for a particular situation. The theory states that there is no one leadership style that is suitable in all situations, thus making success to be myrmecophilous on a number of factors including the style of leadership chosen, qualities of the followers and features that defines that particular situation.Situational TheoriesAt the same time as behavioral theories presented the idea of different leadership styles, they provided petite direction as to what is needed for effective leadership behaviors in diverse situations. Researchers have proven that there is no one leadership style is best suited for every manager under all situations. Therefore, the sentiment of situational theories was developed to give direction that the style to be used is dependent upon such environmental variables factor. Fiedler (1964, 1967) suggested that there is no single best port to lead instead the leaders style should be selected according to the situation. He differentiated between managers who are task or human relationship oriented. chore oriented managers concentrate on the task at hand have a tendency to do reveal in situations that have good leader-member relationships, organized tasks, and either weak or strong position power. Such leaders have a tendency to show a more indicative leadership style. Managers who are relationship oriented do better in all other situations and show a more participative style of leadership.Transformational LeadershipThis concept of transforming leadership was first developed by crowd MacGregor burn down. According to him, transforming leadership is a process by which leaders and followers help each other elevate to higher morality and motivation (Burns, 1978). At the center point of this concept is the importance of th e leaders cleverness to motivate and empower his/her followers and also the moral dimension of leadership. Burns notions were then developed into the idea of transformational leadership where the leader transforms followers The goal of transformational leadership is to transform people and organizations in a literal sense to change them in mind and heart enlarge vision, insight, and recogniseing illuminate purposes make behavior congruent with beliefs, principles, or values and bring about changes that are permanent, self-perpetuating, and momentum building. (Bass and Avolio, 1994).In closing, leadership styles depend on the situation of the business or organization, there is no single style that is suitable. Also, blend leadership with aggroup building, a leader can create an ensample team thus team members may become more involved and ask questions like who does this? Who did that? How am I helping to achieve a common goal?Characteristics of a LeaderEvery individual is insp ired or motivated in a different itinerary it is for this reason that being a leader will require a circumspect combination of different leadership characteristics and skills. Personality traits and characteristics will determine the resistant of leader one is. These characteristics that make up a leader are vast and they are all influenced by the followers, meaning depending on who he/she is leading, a leader will have different characteristics ranging from being self-assured to being initiative.The United States Marine Corps teaches more than ten leadership traits, such as being dependable and enthusiastic. Below is a full list that is taught by the US Marine CorpsJustice intellectDependabilityInitiativeDecisivenessTactIntegrityEnthusiasm driftUnselfishnessCourageKnowledgeLoyaltyEnduranceRetired General Colin Powell believes a good leader has the quality to make decisions that everyone can understand. In his own words, lesson number 14 teaches that nifty leaders are almost in cessantly great simplifiers, who can cut through argument, debate and doubt, to offer a solution everybody can understand. Effective leaders understand the KISS principle, gamble It Simple, Stupid. They articulate vivid, over-arching goals and values, which they use to drive daily behaviors and choices among competing alternatives. Their visions and priorities are lean and compelling, not cluttered and buzzword-laden. Their decisions are crisp and clear, not tentative and ambiguous. They get under ones skin an unwavering firmness and consistency in their actions, aligned with the picture of the future they paint. The import clarity of purpose, credibility of leadership, and integrity in organization.Sam Walton, make of Wal-Mart, tag another great leadership quote and amongst those quotes is Outstanding leaders go out of their way to boost the self-esteem of their personnel. If people believe in themselves, its amazing what they can accomplish. In the following paragraphs I am going to bold some of the key skills a leader is required to have. steamy Intelligence is another concept that serves as a quality a leader should possess and was introduced by Daniel Goleman. Its the ability to perceive, control and then try emotions (Daniel Gloeman, 1998). The people who have researched about emotional intelligence activity say that it can be learnt and some say that it can be produced also. In 1990, dig Salovey and John D. Mayer defined emotional intelligence as the subset of social intelligence that involves the ability to monitor ones own and others feelings and emotions, to discriminate among them and to use this information to guide ones thinking and actions. There are four branches of emotional intelligence Perceiving Emotions, debate with emotions, Understanding Emotions, and Managing Emotions.According to Nitin Nohria, a professor at Harvard Business School, talk is really what a leader does most of the time. He proposes that great leaders follow or s hould follow oratory communication fundamentals. He believes that a leader can communicate any type of message no matter how complex it is. Aristotle said that people can be reached in by means of different methods people can be handle in a way that it will charm their emotions and we can make arguments on their sense of value but the great leaders give a lot of their time communicating. According to Joe Badaracco, another professor at HBS, Simplicity is very essential at every step of communication, that no matter how complex the message, a great leader can convey a message as simple as possible and in fewer words. Communication can however be more expeditiously and effectively be conveyed if the correspondent knows the audience. Great leaders always understand the worth and position of their audience. They know their audience well and in this way they can communicate with their audience in a far better way. He further states that being a good communicator is not enough to be a g ood leader since it will be a two way communication the leader must also be a good listener to avoid misinterpretation from the audience. Jeff Bezos, the chief operating officer and founder of Amazon.com says that one of the key elements of being a good leader is the ability to tell the hard truths and realities. All these examples come under better communication.As I have mentioned before, organizations are rapidly changing, thus making them dynamic. Great leaders are those who can manage and cope with these organizational rapid changes and all its employees or members. They know and comprehend the value of change and accept the common vision of desired results. Empowerment is also important in managing the change process. Managing the change successfully makes ordinary humans the great and effective leaders. People often resist change for reasons that make good sense to them, even if those reasons dont correspond to organizational goals. So it is crucial to recognize, reward, and celebrate accomplishments. (Kanter).In this current age, technology is one of the things travelling on the fast lane. It is report that a technological of most things such as information systems create by mental act every six months. It is for this reason that a great leader must prolong him informed and aware of such evolutions. Knowledge is the key to success and they key element of effective leadership. Great and effective leader must have noesis about everything that he is interacting with. Joe Badaracco says that in the previous days, the leaders had to rely on their subordinates for collecting and implementing the knowledge but now a days, the leaders must be good enough in knowledge so that they can cope with different situations well. Another consequence of fast changing technology is that managers are required to be creative. Creativity is congruous one of the key elements and quality of a great and effective leader. This is one quality that can distinct a leader from a great and effective leader.Examples of some best leaders and managersIt is not easy to find a great leader, especially when the organization plays great game of blaming each other on anything that goes wrong within itself. Few companies have good, solid leadership from people who are willing to stick to their word. Glen Stansberry a writer, in his online article he has identified the following 5 of 10 leaders considered to be good examples in our society.James Parker Southwest AirlinesSouthwest is know for their great customer service in an industry considered to be icky at customer service. Southwest stands out from other skyways by lay the customer first, regardless of the situation at hand. After 9/11 terrorist attack, airlines were not operational for number of days. As a result, all airline passengers, flight attendants and pilots were stuck with the planes across the country unable to travel to their destinations. Instead of but sitting and waiting, Southwest employees were encouraged to take passengers bowling or to the movies to pass the time. Also, other airlines were retrenching their employees by 20%, but James Parker decided to keep all the employees and even announced a profit sharing honorarium of US$179.8 million.Jim Lentz ToyotaIn the year 2009, circa Toyotas 2.3 million vehicles were recalled for faulty brakes. Outrage ran rearing across the media and public. Instead of letting a Public Relations team deal with the problem with only pressure level statements and interviews, Toyota offered a live communion on one of the most aggressive and popular communities on the blade known as Digg. They were all caught by a surprise when the Toyota CEO Jim Lentz appeared on Digg Dialog to be questioned all sorts of queries about the company and the recall. over a thousand hard questions were submitted from consumers and even past employees, and Mr Lentz answered as some as possible in the given time. The questions were asked in order of vote s, and no(prenominal) were filtered therefore making it a totally transparent interview. Even though the number of recalled vehicles skyrocketed, Toyotas honesty and transparency will help with lessening the disability to the companys reputation.Glenn Kelman RedfinRedfin is an online real estate brokerage firm that gives back two-thirds of the commission that traditional agents charge. Real estate agents hated it, and started blacklisting anyone who used the service. So, instead of keeping the problem quiet, Kelman started a company blog that focused on many of the howling(a) aspects of the real estate business. He also posted about privileged struggles within the company, and even criticized himself on many occasions. The blog was raw and authentic. Customers love the transparency. They appreciated the fact that a CEO could make fun of himself and the noisome parts of his industry. Since starting the Redfin blog in 2006, business has grown dramatically. (Glen Stansberry, 2010 ).Costco Jim SinegalCostco net worth value is ranked at U$2 billion, but the CEO Jim Sinegal only gets US$350,000.00 per annum. In general, most employees tend to get de-motivated by the fact that their bosses earn a lot of money and do not really care about them. It even gets worse when an employee does not see the head of the company. In Jims case, he has a simple office, on the same floor with his employees and without any walls and decorations, and answers his own telephone. His employee turnover rate is the worst in the retail industry, over five times less than affect Wal-Mart. In an age where CEOs are paid in the millions and would never be seen in the trenches, Jim Sinegal is an anomaly. And his workers love him for it.Howard Schultz StarbucksStarbucks is known for its exceptional treatment of employees, offering things like insurance to even part-time workers. In 1997 three employees were killed in a bumbled robbery of one of their Washington D.C. stores. Instead of iss uing a press release or calling legal counsel, CEO Howard Schultz flew straight to D.C. and dog-tired the entire week with the employees and their families in the area. Schultzs compassion and incredible leadership helped meliorate those closest to the tragedy.ConclusionRegardless of the extensive research about the importance of management and leadership in terms of individuals, organizational executing, and national performance there is still a lack of realistic evidence. According to the scotch analyses, even though management and leadership are the integral part in influencing national competitiveness, their influence is just another factor of many others. Strictly at organizational levels, it may seem like leadership and management are the only factors that have a direct influence on results, however they are just part of Human option Management activities. The influence of Management and Leadership development (MLD) at an individual level, it seems to be affected by the t ype of intervention and the wish and the break of individuals to take on leadership responsibilities. These however may not speculate positively on the influences of management and leadership with regard to performance.This report may show how important it is to consider leadership in the broader context of any organization. Separately, there is no assurance that leadership development will reform the individuals performance, however, if we look at leadership development as the main thing within and organization and human resource management (HRM) processes its influence becomes obvious. Similarly, the availableness of effective leadership and management processes inside an organization raises the probability of additive training and development becoming a success.Regardless of the lack of definitive evidence indicating the relationship between management, leadership and performance it has been widely accepted that this are the key elements of effective performance of groups, i ndividuals, organizations, etc. The fact that this relationship cannot be linearly measured indicates that there is a need for more research to be done. The way in which enhanced management and leadership leads to improved performance is complex and thus when looking at the benefits that are raised from the interventions a much wider idea of performance needs to include instead of just looking at improved productivity/profit.