Philosophy

Institutional Affiliation Exercise, Anxiety, and Depression
Over the years, exercise has been linked to improved moods of patients specifically anxiety and depression.  There are models developed to explain how exercise improves peoples mood.  Physiologic changes thought to be brought about by exercise are explained in the hyperthermic model and the endorphin hypothesis.  Improved moods caused by changes in the psychological state after exercise are also illustrated in models that discuss self esteem and mastery explanations and the distraction hypothesis (Daley, 2002).

Many researchers have dedicated their time and effort to finding evidences to support the thesis that exercise reduces anxiety and depression.  The type of exercise that research studies correlate with the reduction of depression and anxiety symptoms involves the use of the bodys muscular strength, flexibility, and cardiovascular endurance (Stuart  Laraia, 2005).  Providing sufficient empirical proof to this thesis will significantly benefit stakeholders of the healthcare system.  Not only will it lower the costs of treating mental health problems such as depression and anxiety, but it will also contribute to the research and development of nonpharmacologic interventions used to treat these problems.  As such, this paper aims to provide a systematic review of literature supporting the thesis that there is a relationship between exercise and a resulting reduction in anxiety and depression.

Review of Literature and Discussion
In a fact sheet released by the University of California Santa Cruz (UCSC, n.d.), they discussed how exercise leads to improvements in a persons mood and development of a sense of well-being.  They provided information based on researches on how exercise makes anxious people feel relaxed.

Supporting details include statements that both single sessions and regular exercise reduce anxiety.  Furthermore, exercise was shown to have greater beneficial effects in people clinically diagnosed with anxiety disorders.  They also provided statements that summarize research results suggesting that exercise reduces depression.  Researches showed that both aerobic and anaerobic exercises pull out a person from a depressed mood.  Likewise, exercise is shown to have an antidepressant effect on patients diagnosed with depression (UCSC, n.d.).

In a research article by Hamer, Stamatakis, and Steptoe (2009), they concluded that engaging in any physical activity for at least 20 minutes per week results in lesser risk of having pyschological distress.  In this research, they surveyed 19,842 men and women who came from the Scottish Health Survey as participants.  They measured the psychological distress of the participants through the use of the General Health Questionnaire wherein a score of 4 or more indicates psychological distress.  Measure of physical activity per week was obtained through logistic regression model calculations.  Based on their results, it was suggested that higher levels of physical activity will result in higher reduction of psychological distress (Hamer et al., 2009).

A similar study conducted by a group of doctors revealed that aerobic exercise at a dose consistent with public health recommendations is an effective treatment for MDD major depressive disorder of mild to moderate severity and a lower dose is comparable to placebo effect (Dunn, Trivedi, Kampert, Clark,  Chambliss, 2005, p. 1).  One of the four randomized groups in this study was exposed to an aerobic exercise treatment plan which used the recommended standard for physical activity while others were exposed to either a lower exercise regimen or placebo control.  Outcomes were measured through scores generated from the 17- item Hamilton Rating Scale for Depression (Dunn et al., 2005).

Numerous research studies provide data that compare the anxiety levels and depressed state of an exercise group and a no-treatment control group.  Their data suggest that the exercise groups have less anxiety and depression than the control groups.  In this line, a recent study used control and experiment groups to identify effectiveness of exercise in reducing depressive symptoms of participants aged 18 to 23 years old.  In order to compare the difference of results between groups, they used a pre-testpost-test method wherein the participants answered the Beck Depression Inventory before and after the 5-week exercise regimen.  In addition to this, they obtained saliva samples for DNA analysis.  Based on their results, it was suggested that the mechanism with which exercise produces reduction in symptoms of depression is likened to the effects of selective serotonin uptake inhibitors, a type of a pharmacologic antidepressant.  This strengthens the idea that exercise should be legitimately used for the treatment of depression (Rethorst, Landers, Nagoshi,  Ross, 2009).

In another research study, participants with symptoms of anxiety were engaged in a 2- week exercise treatment plan where outcomes were assessed prior, during, and after the exercise regimen.  Results showed that exercise reduced anxiety sensitivity which leads to alleviation of the depressed and anxious mood (Smits et al., 2008).

Some research studies also employed methods of self-report from participants regarding their physical activity and mental health through the use of questionnaires.  In a study conducted by De Moor, Beem, Stubb, Boomsma, and De Geus (2006) among families with adolescent and adult twins in Netherlands, their research findings concluded that regular exercise is associated with lower neuroticism, anxiety and depression and higher extraversion and sensation seeking in the population (p. 273).

In a prospective research study, it was concluded that there is a two-way relationship between exercise and depression.  This indicates that higher levels of physical activity reduce depression while depression reduces levels of physical activity in the future.  This implies that interventions should be directed at increasing physical activity among populations that are most at risk of developing depressive symptoms (Jerstad, Boutelle, Ness,  Stice, 2010).  A prospective research study may not be as good as a randomized clinical trial, but its yielded results are still reliable.  However, one possible limitation of this study is that participant responses may have been affected since the study was conducted over a long period of time.  Events that may affect any aspect of a persons life may also affect their response in the study such as pregnancy, death, etc.

There are also a number of research studies dedicated in providing support to the thesis by employing a method of review analysis of research articles.  In line with this, a group of researchers did a systematic review of 40 scholarly journal articles (1995- 2007) about the sedentary lifestyle of chronically ill patients.  Meta- regression analysis was employed and it was concluded that exercise reduces the symptoms of anxiety in chronically- ill patients who live a sedentary lifestyle (Herring, OConnor,  Dishman, 2010).

Another systematic review of related research articles was conducted in 2007 and 2008 which concluded that exercise reduces symptoms in clients with depression.  The group reviewed research articles which contained randomized clinical trials that observed effects of exercise on experiment and controlplacebo group.  They also suggested that more systematic reviews should be conducted to determine effect of exercise in people who manifest depression but are not clinically diagnosed with depression (Mead et al., 2008).

A Polish research article discussed meta-analyses of both experimental and correlational studies that showed reductions in anxiety and depression in both healthy and clinical patients after aerobic exercises are performed in a specific period of time.  It explained that this effect of exercise in the alleviation of moods is associated with the theories relating physiologic releases of endorphins and monoamines (Guszkowska, 2004).

Summary and Critique
There are available recent evidences that can best support the thesis that there is a connection between exercise and a resulting reduction in anxiety and depression.  The availability of methodologically sound researches and high-level evidence-based studies indicates that there are strong and reliable bases for the thesis.  This also supports the idea that research and evidence aid in the implementation of new innovative techniques in treating health problems, in this case, exercise for the reduction of anxiety and depression.

The strength of the research studies discussed is its quality of evidence base.  Two of the first five research studies cited are randomized clinical trials while the other two are quasi-experiments.  In the hierarchy of evidence-based studies, randomized clinical trials and quasi-experiments are high up in the evidence pyramid (SUNY Downstate Medical Center, 2004).  This indicates that empirical proofs to this thesis are highly recommended evidence bases.  It is commendable that their methods involved field-testing of exercise and the pretest-posttest assessment of the mental health status of the participants.  In comparison to merely asking or surveying people regarding their physical activity, engaging the participants in an actual exercise program is a better way of finding out the results.

The actual field-testing of the exercise variable increases the likelihood that people will believe the results of the research.  People learn more from lived experience rather than just theoretical learning, for example, books or journals.  Ideally, the target audience of these studies is the general population who need to be encouraged to include exercise in their daily routine because it helps reduce anxiety and depression.  Hence, studies should be able to communicate this with the larger population who do not understand scientific jargons and tend to only believe what they see or what they can relate with.  In this case, people who can testify that they actually engaged in an exercise program that resulted in their improved mood are something that the general population can relate with.  Therefore, it is easier to convince people that the health action can really lead to improved health outcomes.

The significance of a study justifies that a study is ethical to conduct.  It can be assumed that the significance of these studies focus on proving that exercise can reduce anxiety and depression for both healthy and ill people to the alleviate the conditions.  In effect, the idea of exercise as a health promoting activity to prevent anxiety and depression was also addressed in these research studies.  This is a good outcome of the researches because at present, efforts are pushed toward health promotion and disease prevention instead of waiting for the disease before treating it.  Though there are still arguments and conflicts among researchers about the legitimacy of exercise in reducing anxiety and depression, this new theory about exercise already encourages people in engaging in a healthy habit.

Based on the studies discussed, one common potential limitation of these research studies is patient-response bias in answering the self-report questionnaires used to assess the mental health status of the participants.  This is due to the possibility that patients may not truly reflect their personality or behaviors in the questionnaires.  They may choose an answer that reflects what they want themselves to be or to do rather than what they are doing in reality.  Nevertheless, it must be remembered that these tools are valid and has high sensitivity to screening depression (Lincoln, Nicholl, Flannanghan, 2003).  Hence, this limitation is only part and partial of the overall studies.

Another potential limitation is the representativeness of the number of samples used in these research studies.  Getting a large number of participants in a research study is very difficult.  Hence, most research studies use a small number of samples to generate data from.  This makes it difficult to apply to the general population the conclusions drawn from the studies.  This is one possible aspect in researches that needs improvement.  In order to have legitimate and reliable claims, data should not only produce good statistical data regarding the variables involved but also present a large proportion of the population to whom the study was conducted.

Some of the research evidences also mentioned include systematic reviews and meta-analyses.  These are ways to determine the quality use of the best current evidence and these two are the topmost in the evidence pyramid (SUNY Downstate Medical Center, 2004).  It is good to know that recent systematic reviews suggested and supported the thesis that exercise reduces symptoms of anxiety and depression.  This strengthens the stance that there is an existing relationship between exercise and a resulting improved mood.  This is also an indicator that previous researches provide sufficient support to this thesis.  However, a possible limitation that should be considered here is selection bias of research articles included in the systematic review.  It is best to increase the number of researches reviewed in proportion to all recent research articles published regarding this thesis in order to eliminate selection bias.

The researches discussed contribute in building a more convincing assertion for the thesis.  They may have their own scope and limitations but a combination of previous and recent researches lead to a stronger foundation for theories that are not yet scientifically proven.

This article supports a theory which explains autism, a mental disorder. Indicators of Autism will be discussed in detail in this paper. According to American Psychological Association (APA), Autism can be analyzed in two stages and those 2 stages will also be discussed later. Experiments which had been done on the Autistic person and the researches on Autism will also be discussed later.
     
About autism, it had been observed that it is usually found in children, at the early stages of their lives. It appears mostly within the first 3 years of life. Autism is known as Autism Spectrum Disorder (ASD) in the medical world. Autism is also known as Brain development disorder. An Autistic person behaves in a different manner as compared to normal person. He faces numerous difficulties in his daily life, especially when he comes into changeable and uncertain environments.
     
Autism may be from the birth of child or may be visible in early years of hisher life. Autism is a disorder which mainly affects the working of the mind. It is an obstacle in the development of mind. Social interaction and communication skills are affected by Autism. People affected by Autism face problem in verbal and non-verbal communication. They also experience problem in communicating ideas and feelings, imagination, social interaction and leisure or play activities.
   
It is analyzed by the American Psychological Association (APA) that 1 out of 166 births is affected by this disorder. On the basis of this analysis it can be stated that at present 1.5 million Americans are suffering from autism. The effect of autism is consistent around the globe. Boys are four times more affected by this than girls. Racial, ethnic, or social boundaries cannot bound autism. Family income, lifestyle, and educational levels cannot change the effect of autism. It is free from all these things.    

Certain set of behaviors are used for defining autism spectrum disorder (ASD). There are many indicators for identifying ASD. Public Health Training Network Webcast defined some indicators.

These indicators are-
 Does not babble, point, or make meaningful gestures by 1 year of age
 Does not speak one word by 16 months
 Does not combine two words by 2 years
 Does not respond to name
 Loses language or social skills

Poor eye contact, Doesnt seem to know how to play with toys, Excessively lines up toys or other objects, Excessively lines up toys or other objects, Is attached to one particular toy or object, and Doesnt smile are some other indicators of ASD. ASD is first time detected by the parents of the child. This is noticed by the different kind of behavior of child. Thats why General Physicians or the Pediatricians notice early behavior of the child.

This disorder is analyzed in two stages.
In first stage childs behavior is analyzed by the pediatrician. This analysis is done by the observations given by the parents.

In second stage analysis is done by the team of psychologist, a neurologist, a psychiatrist, a speech therapist, or other professionals for identifying ASD.

Earlier it had been thought that autistic children face difficulty in interpreting state of mind on the basis of facial expression. But American Psychological Association (APA) did an experiment over 18 autistic children of the age between 10 to 14 years. Some images, in which facial expression was static or freeze, had been shown to those children. Most of them were not able to interpret the state of mind on the basis of static facial expression. But they were able to do that when animated or dynamic imaged had been shown.  It signifies that autistic children can understand mental states when information is conveyed by eyes and mouth.
     
A protein, carnosine is attracting many researchers towards the study of Autism. An experiment had been done on 31 autistic children. In which those children had been given a synthetic form of carnosine, called L-carnosine for 8 weeks. After 2 weeks an improvement was found that in those autistic children. There was some improvement in their communication ability, recognizing power and eye contact. There were improvements in communication and behavior of 60 children and 27 were now more socialized. It was the result of this experiment.
   
I support these experiments and researches. A better care and good treatment could be the tools to close this mental illness. Now days a small but an important portion of world population, is facing this problem. Efforts had been made in this direction and lots of efforts are being made in this field by many countries. Movies and documentaries based on autism have been released recently to make the world aware about this disorder. It is going to become a big research field during the coming days.  Research on autism has begun to explain the causes, remedies and caution related with this mental disorder.

Experiments and researches have been done at every level. Next few years will bring further expansion in this biological field. Experiments and researches which had been done in this field will definitely be useful in future for further research in this field.

There are no existing measures of reintegration for injured service members. Some measures are too narrow and unable to cover the aspects or dimensions of community reintegration. Others are too broad by covering two or more dimensions of integration and preventing the assessment of these dimensions as individual constructs. In developing a measure for community reintegration of injured service members, the International Classification of Functioning, Disability and Health (ICF) developed by the World Health Organization was the basis. The ICF defined community reintegration in terms of participation in the community measured through these nine dimensions learning and applying knowledge general tasks and demands communication mobility self-care domestic life interpersonal relationships major life areas and community, social and civic life (Resnik, Plow  Jette, 2009, p. 470).

In adopting these dimensions, two areas were considered. One is functioning and disability specifically assessed through body functioning, structure, activities and participation, with activities and participation merged by not including simple tasks in the measure. The other is contextual considerations pertaining to personal and external environmental factors.

To rationale of the current study is to develop a community reintegration measure for those returning with injuries from serving in Iraq. The outcome supports the evaluation of the reintegration of returning service members in the community to determine reintegration problems for individuals in a timely manner and respond to these problems in a timely manner. The results of the study also fill the gap in measures for community reintegration of injured service personnel.

The purpose of the study is two-fold. One is to create a reintegration measure for returning service members with injuries with focus on participation. The other is to test CRIS in terms of the reliability and validity of the measure.  

The research question, which is implied from the purpose of the study, covered the basis or source of the new community reintegration measure as well as the reliability and validity of the measure. There was no clear mention of the hypotheses of the study in the introduction.

Evaluation
The theoretical background presented in the study is relevant with the ICF comprising the basis of the new community reintegration measure. The dimensions of reintegration based on the ICF also served as a definition of reintegration. An entire section explained the concept of participation, which is one of the dimensions of reintegration. This indicated the focus on participation in measuring community reintegration. There was no theoretical or conceptual discussion of the other dimensions of reintegration.

Indication of the lack of community reintegration measures for injured service personnel justified the need for the study. The study addressed this gap by developing a new measure of community reintegration and testing the measure on injured returning service personnel.

The objectives were clearly identified and set out in the introduction section. The two objectives were numbered and explained in the purpose of the study.

The research question was not explicitly identified. This was implied from the rationale and purpose of the study. There was also no discussion of the hypotheses or expected outcomes in the introduction. There were not identifiable by reading the introduction section alone.

Methods
Summary
There were two groups of participants in the study. The first group comprise of veterans of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) (Resnik et al., 2009). In the two pilot studies, the veteran participants were selected through convenience sampling from those obtaining services from Providence VA Medical Center (PVAMC). The veterans provided data on the three dimensions comprising the measure and the resulting measure was tested on veterans. Nevertheless, efforts were made to represent employment, domestic roles and other factors. The second group comprise of professional caregivers and clinicians (Resnik et al., 2009), which were impliedly selected via purposive sampling, to have respondents representing physical and mental health care, with significant experience of cases of returning service personnel. These respondents provided feedback during the formative stage of the study.

Interview was the data collection instrument during the formative stage of the research. The interviews of veterans, caregivers and clinicians targeted the identification of community reintegration problems of injured veterans. The interview responses identified problems categorized under frequency of participation, perceived limitations in participation, and satisfaction with participation (Resnik et al., 2009, p. 471). The interview resulted to the intended outcomes reflecting on the validity of the instrument. These items were translated into a comprehensive questionnaire used as the other data collection instrument in the pilot studies. The testing of the measure indicated significant reliability between the results of the two pilot studies. The assessment of the instrument also showed significant content, construct, convergent and discriminant validity (p.476) as determined by face validity and Rasch residual factor analysis (Resnik et al., 2009.

Positivism is the research paradigm used to define the parameters of the study. The purpose is to create and test a community integration measure for service veterans. This required systematic data providing a scientific explanation of the phenomenon studied (Creswell, 2003). Although the measure was intended to reflect the perspective of veterans and apply to measures to them, the study and the research process are systematic. The study also tested the ICF constructs and the hypotheses on the expected outcomes of the instrument testing.

The study employed a mixed research design combining qualitative and quantitative research (Creswell, 2003). The formative stage is a qualitative study by interviewing veterans, caregivers and clinicians. The two pilot studies and the testing of CRIS scales were quantitative by using questionnaire responses analyzed quantitatively to determine reliability and validity.

The study was done in three stages. In the formative stage, the research collected data on the reintegration issues, focusing on participation. These issues were classified into three dimensions of participation. Within these dimensions are sets of questions formed into a single questionnaire. The first pilot study tested the reliability of the instrument. The second pilot study tested the validity of the instrument. Items determined as misfits from each pilot study were removed or modified. The last stage assessed the three scales (dimensions) of participation.

Evaluation
Using the convenience sampling technique limits external validity. The sample may not be able to represent the range of community reintegration problems faced by the entire population of injured OIF and OEF veterans.

The use of interview in the formative stage and questionnaire in the pilot studies were appropriate in supporting the data requirements of the study. The interview results supported the creation of the measure and the questionnaire responses were used to evaluate the reliability and validity of the study. Other data collection methods may not be able to address the purpose of the study in the same way.
Positivism was the appropriate research paradigm since the thrust of the study was the scientific collection of data to support the development of a community reintegration measure for injured service veterans.

The combination of qualitative and quantitative research was appropriate in addressing the research question implied from the purpose of the study. Qualitative data supported the creation of the instrument measuring community reintegration, with focus on participation. The quantitative data informed on the reliability and validity of the instrument for application to the population of returning service personnel. Using a mono-method research design would not sufficiently address the purpose of the study.

The procedures in the formative stage of the research were not thoroughly explained since these were reported in another study. This study has to be consulted to replicate the formative stage. The procedures for the pilot study were clearly explained to support replication. The results of the CRIS scale scores were not shown in the study to limit the replication of the CRIS scales assessment stage.

Data Analysis
Summary
Content analysis is the analytical method used on the qualitative data in the formative stage of the research. Content analysis was used to assess the problems identified in the interview and classify these into the three dimensions or scales of participation. Descriptive and statistical methods were employed to analyze data from the pilot studies and the scales assessment. The descriptive statistics used included frequencies, averages or means and other summative techniques. The Item Response Theory (IRT), specifically the Rasch model is a statistical tool used to measure the reliability and validity of the instrument or scale. Analysis of Variance (ANOVA) was used in determining the variance in the data falling under the three scales. General linear models were employed to assess individual characteristics such as age, employment and post-traumatic stress disorder (PTSD) with the three scales.

The content analysis led to 97 statements on extent of participation, 116 statements on perceived limitation in participation, and 83 statements on participation satisfaction (Resnik et al., 2009) reflecting the various problems encountered by injured veterans during community reintegration. The descriptive and statistical analysis determined the statements considered as misfits based on measures of reliability and validity. The final instrument is comprised of 97statements on extent of participation, 107 statements on perceived limitation in participation, and 85 statements under participation satisfaction (Resnik et al., 2009), with the statements reflecting significant levels of reliability and validity.

Evaluation
The data analysis techniques were adequate by supporting the thorough analysis of the items included in the measure and testing for reliability and validity of the instrument. The data analysis techniques also matched with the qualitative or quantitative nature of data assessed.

The presentation was incomplete. The result of the interview in the formative stage of the research was not shown. The CRIS scale cores analysis was not also shown in the study. The items included under the three scales were not identified and the items changed or modified were also not indicated. While the study identified the three scales comprising the instrument, the items under these scales were not shown in the text or even in an appendix.

The authors identified the limitations in their study as the derivation only of estimates for the entire population based on data from a small sample. The authors also identified the employment of CRIS in a broader population and use of the CRIS as an instrument administered via computer as areas for future research.

Conclusions
Conclusion I
Summary
The resulting instrument (CRIS) is comprehensive by focusing on the various participation problems encountered by service veterans. The instrument is a reliable and valid measure of the community reintegration of returning injured service personnel.

Evaluation of internal validity
This conclusion was based on the results of the content analysis, descriptive analysis, and statistical analysis used on the treatment of the data collected from the three stages of the study. The conclusion responds to the research question implied from the purpose of the study by pointing to the creation of a new community integration instrument and the significant levels of reliability and validity of the instrument. The conclusion relates to filling the lack of community integration measures for service veterans mentioned in the introduction. The possible threat to internal validity is the comprehensiveness of the items given that the items were based on interviews of a limited a number of respondents. The study explains this threat by recognizing the value of the items as approximations of the community integration experiences of service veterans. This conclusion is consistent with the results of the study and falls within the scope of the investigation.

Conclusion II
Summary
Computer-adapted testing and broader IRT can be used to improve CRIS by minimizing the burden to respondents of answering the lengthy instrument.

Evaluation of internal validity
This conclusion does not directly follow the data analysis. There was no previous discussion of problems in responding to the questions or in analyzing the data because of the length of the instrument. This conclusion is based on the limitations of the study and the areas for future research. This conclusion responds to the research question in so far as to provide direction in further developing CRIS. This conclusion does not relate to any findings discussed in the introduction, which focused on the lack of community measurement instrument and not on the burden of instruments on respondents because of length. The possible threat to internal validity of this conclusion is its characteristic as an after-thought to the development of CRIS and not directly linked to the findings. While this conclusion is not inconsistent with the other conclusion, this is outside of the scope of the findings.

Modifications to the Current Study
A number of modifications in the methodology of the study are recommended to improve the internal validity and allow replication. First is an increase in the number of respondents. There were 14 veteran respondents in the formative stage. Increasing the number of respondents could yield to problems in community reintegration not covered by the current study. There were 50 and 76 respondents in the two pilot studies respectively. Increasing the number can lead not just to approximations but to generalizations. Second is obtaining respondents from different venues, medical and social service institutions for veterans in other states, not just at Providence VA Medical Center. This supports a more geographically and possibly demographically representative sample. Third is the use of stratified random sampling to enhance representation of the research population in terms of socio-demographic, health and other characteristics that lead to better representation and affect the results of the study. These modifications enhance the drawing of inferences and generalizations.

According to the Agency for Healthcare Research and Quality (1999), Depressive disorders are grave and disabling diseases. It is approximated that at least one out of five people are affected by this disorder in their lifetime. This disorder brings about devastating economic effects to the individual and to the family. In the United States alone it is estimated that financial costs for the management of depressive disorders are higher than 44 billion (Agency for Healthcare Research and Quality, 1999).

Personal impacts of the disease are reflected by the high rate of mortality as well as impairment in multiple areas of functioning. WHO approximates that depressive disorders are the fourth most significant causes of disability globally. The United States Department of Human Health and Services in the late 1980s, as indicated by the Agency for Healthcare Research and Quality (1999), supported the establishment of standard guidelines for depressive disorders especially major depression. These guidelines played a very important role in advancing knowledge although evidence was inadequate to deal with numerous clinically significant questions. From that time onwards, publicized focus on dealing with and treating depression and also on the development of various antidepressants have resulted in tremendous growth in prescribing of antidepressants in addition to increasing costs for health plans. Clinicians have been faced by confusion in making a choice between herbal remedies and novel antidepressants.

This report is aimed at helping clinicians choose wisely between herbal remedies and new antidepressants. It also aims at assisting organizations establish clinical guidelines for the treatment of depressive disorders. A far reaching assessment of the advantages and the disadvantages of herbal drugs and new antidepressants for use in the treatment of depressive disorders in both adults and children, are provided in this report. Various newer pharmacotherapies and herbal drugs are focused on in this report. Antidepressants developed earlier are only considered when they are being compared with a newer antidepressant (Agency for Healthcare Research and Quality, 1999). This report addresses the efficacy of newer antidepressants for use in the management of most prevalent forms of depressive disorders. It also addresses questions regarding the efficacy of newer antidepressants as compared to psychosocial therapies as well as the efficacy of herbal treatments. Specific populations are focused on in this report children as well as adolescents in specific settings (Agency for Healthcare Research and Quality, 1999).

Literature was extracted from special records of about 8, 415 articles dealing with clinical trials and references from relevant meta-analysis and professionals (Agency for Healthcare Research and Quality, 1999). Trials in these records addressed depressive disorders identified from numerous sources including electronic databases. Evaluation of sources was carried out within a period of 18 years, from 1980-1998, so as to obtain literature pertinent to new pharmacotherapies.  Various terms referring to depressive disorders were put together with a list of newer antidepressants as well as herbal therapies to make 1,277 records (Agency for Healthcare Research and Quality, 1999).

Randomized controlled trials that lasted for six weeks were reviewed. Most of these trials compared a newer antidepressant with an older one, a placebo or a psychosocial therapy. Most trials involved patients of depressive disorders who had a clinical outcome. This review identified grave but rare effects of various drugs. Articles from databases were searched based on the effects of various drugs.

Specific words such as serious, sever, adverse, and poisoning were used during database search for articles (Agency for Healthcare Research and Quality, 1999). Data obtained from each clinical trial was independently abstracted by two people. It was then synthesized descriptively focusing on participants as well as diagnostic descriptors, characteristics for intervention, designs of various studies, and outcomes of the trials. Empirical Bayes random-effects estimator technique was used to qualitatively analyze some data. The most important results were response rate of symptoms, dropouts, and the rate of discontinuation as a result of serious effects. Response rate, according to Agency for Healthcare Research and Quality (1999), was recorded as 50, or more symptomatic improvement, as evaluated using a depression symptoms rating scale. These rates were calculated with the help of a modified intention-to-treat approach. Considering that some of those who dropped out of the study may have responded, analysis using the modified intention-to-treat generated a conservative approximate of the effect of treatment. Based on endpoint technique a sensitivity test was carried out with the denominator for the risk ratio being the number of those who completed follow up (Agency for Healthcare Research and Quality, 1999).

Approximately 300 randomized trials assessed new antidepressants with most of them focusing on major depression.  Other studies focused on dysthymia, subsyndromal and anxiety disorders (Agency for Healthcare Research and Quality, 1999). More than 100 trials compared the efficacy of new pharmacotherapies to placebo. Most trials, as illustrated by the Agency for Healthcare Research and Quality (1999), used a double blind method that lasted for about 6-8 weeks. Reporting of most of these trials was incomplete. Very few studies described the setting of the study, nature and the content of clinical relations between participants and providers, the socio-economic status and cultural background of the participants. Secondary results were also reported irregularly for analysis (Agency for Healthcare Research and Quality, 1999).

More than 80 of the studies proved newer antidepressants as more effective drugs as compared to placebo for the treatment of depressive disorders, with response rate being more than half for active treatment and less that half for placebo (Agency for Healthcare Research and Quality, 1999). The study also realized that newer antidepressants are equally effective as compared to older pharmacotherapies. It was concluded that new antidepressants are the drugs of choice for the treatment of depressive disorders. From this assignment I have learnt how the correct procedure to follow while reporting a research. I have also learned that for a drug to be considered effective it has to undergo extensive evaluation.

Prejudice is defined as an unfavorable attitude and behavior towards other people. History has witnessed the pernicious effects of prejudices in the form of genocides, holocausts and colonialism. The most useful tool for expressing prejudice has been language, therefore it is regarded that we can change peoples attitude and prejudices if we if we can change the language they use. Prejudice and discrimination can be both subtle and blatant (Kupetz 37). The relationship of language with prejudice is very strong as the words are the currency of prejudice (Rauch). Purists who aim to eradicate a single tint of prejudice from the society are of the view that as language has been used by the propagandists and biased ones to bring harm to the society, such language must be scrutinized strictly. They also believe that peoples attitude and prejudice can be changed if the language they use is altered in its very nature.

On the other hand some of the writers, mainly pluralists, are against the view of changing language to eradicate prejudice. Prejudices may not be all pernicious in its entirety and therefore need not to be eradicated from any society but the greater need is to channel these prejudices in the positive direction to make the most of it. This is the main reason that some of the journalists have resented the options for abolishing prejudices from the society. Jonathan Rauch is one of the writers who argue that by investing more on prejudices we can be able to take advantage of the underlying prejudices in any society. In his article, In defense of prejudice why incendiary speech must be protected, Jonathan Rauch announces that his article is not for defending any kind of prejudice rather his article is favoring for intellectual pluralism (Rauch). The racist expression is a fruit of freedom of expression and in order to access the progress of knowledge and advancements of science, one has to swalow the bitter fruit of prejudice and accept that for as thickheaded and wayward animal as us, the realistic question is how to make the best of prejudice, not how to eradicate it (Rauch). Prejudices are changeable but the real utility of prejudices can be in using them rather than altering their forms. As Rauch defends the reviving of prejudices on the ground that if intellectual pluralism is promoted in a society prejudices can be made socially productive by pitting prejudice against prejudice and dogma against dogma exposing all to withering public criticism (Rauch). Pluralism, defines Rauch, is the principle that provides space for the minorities against whom the prejudices of a society are targetted. These minorities include the criminals and gay, etc. although they, dissidents, are responsible for the progress of a society. The real threat to pluralism, that defends prejudices to an extent, is from purism which aims to wash away the tints of prejudices without paying heed to the consequent injustices on the subjects of prejudices.  Purism campaigns against the language that is an efficacious tool for prejudice. Rauch holds the view that language does not reflect a persons feelings in all cases, as in Mark Twains novel Huckelberry Finn the use of nigger does not make the book an act of hate speech , and it is an ironic fact the mere utterance of the word nigger by a non-white is a racist act (Rauch).

Some of the researchers see the prejudice as a serious psycological issue that must be given full treatment through guidance and reforming ones attitudes and behavior towards other human beings.But the important point is that prejudice can be changed through language. The need is to implement changes from the authorities to design policies to secure the weaker and stigmatized sections of the society. While the view of utilizing prejudice in a better way also holds an impact if it is applied in the society. But due to the strong relation of language and prejudice the real need for the law enforcing authorities is to pay constant heed to the abuse of language by the prejudiced souls.

Charles Joseph Whitman who was born on the 24th of June 1941 was shot dead by the police after killing 14 people and wounding at least 32 others in a shooting spree around the University of Texas (Sillup). He had previously killed his mother and his wife before orchestrating the deadliest university shooting rampage in the history of the United States before Seung Hui Cho killed 32 people in Virginia Tech in 2007. Charles Whitman had grown up in a complete nuclear family. His father was financially stable, running a successful plumbing business in Florida. His family was however scuttled after a dysfunctional marriage forced his mother to abandon his father and move to Texas (A E Television Network). His father is reported to have been too demanding and required perfection from his wife and kids.

Early life
Charles Joseph Whitmans father attended Bethesda School for Boys in Georgia. His mother Margaret was a devout catholic and met his father still in Savannah, Georgia and after their marriage, they moved to Lake Worth, Florida where Charles Whitman was born (A E Television Network). He and his brothers, Patrick and John, served as altar boys at the Sacred Heart Roman Catholic church where Charles Whitman would later choose the confirmation name Joseph for himself. Charles Whitman was an extremely intelligent child he scored 138 on an Intelligence Quotient (IQ) test when he was six years old. He loved music and sports and undertook piano lessons for five year. Later in high school, he became a pitcher for the school baseball team (A E Television Network).

Charles Whitman excelled in his academics and as reports indicate, he was very much loved by his neighbors and peers. He however complained of migraine headaches, which were later to be attributed to a highly cancerous brain tumor discovered during the autopsy on his body (Macleod). Besides the negative impact on his mind from living in a dysfunctional family, Charles Whitman abused amphetamines and had other health complications.

Charles Whitman Senior had a large collection of firearms and taught his sons how to use firearms at a very young age. He taught them how to clean and maintain firearms and even took them out for target practice exercises (Sillup). It is from here that, as his childhood neighbors would come to report later, that Charles Whitman developed a very keen interest in firearms at a very young age. Perhaps this was ill-informed as when his son finally got the motive, he used his extensive knowledge of firearms to kill so many people.

Struggles with life
When Charles Whitmans family became dysfunctional, he became much stressed to the stage of becoming psychotic (Time). In fact, a psychiatric serving at the University of Texas Health center later disclosed that the discussions he had with Charles Whitman centered on this topic. Against his fathers strong will, Charles joined the US Marines in July 1959. When the catholic father at the Sacred Heart Roman Catholic Church, Father Leduc, asked him to explain his defiance to his father, Charles Whitman alleged that his father had been harassing him (Macleod). He said that on several occasions, Charles Whitman senior had come home drunk and physically assaulted him, sometimes shoving him into the familys swimming pool. If these allegations are true, then Charles Whitmans father contributed greatly into his sons becoming demented.

On September 15th 1961, Charles Whitman enrolled in the University of Texas to pursue a Bachelors degree in Mechanical Engineering under a USMC scholarship. At the university, his hobbies included martial arts, scuba diving and hunting (Lavergne 12). By this time, he had already started to exhibit abnormal behavior. He once went on hunting hike while in campus, killed a deer and dragged in into the hostels and de-skinned it inside the shower of his dormitory. This outrageous prank coupled with poor grades in class prompted the USMC to withdraw his scholarship in 1963 (Time).

The previous year, Charles Whitman had met and fallen in love with Kathleen Frances Leissner, a fellow student at the University of Texas. They had traveled to Kathleen Frances hometown in Texas where they exchanged marriage vows in a wedding ceremony conducted by Father Leduc (A E Television Network). After Charles Whitmans scholarship was withdrawn, he resumed duty with the US military at the Marine Corps Base Camp Lejeune in North Carolina. Even though he was promoted to Lance Corporal, personal woes continued to follow him. To start with, he was involved in a road accident when an army jeep he was driving rolled over an embankment. He was hospitalized for four days.

In the November 1962, Charles Whitman love for firearms put him into trouble at his military station. He was found to be in possession of a personal firearm while on base. In addition, he had become fond of gambling and once threatened a fellow marine who owed him 30 dollars (Sillup). Whitman was demanding repayment plus a 15 dollar interest. These events led to his being court-martialed after which he was sentenced to 30 days confinement, 90 days of hard labor and then demoted from Lance Corporal into a Private.

Charles Whitman was honorably discharged from the United States Army. He returned to the University of Texas where he enrolled to study architectural engineering. Meanwhile, he was working at the Standard Finance Company offices as a bill collector before being hired as a teller by the Austin National Bank (Sillup). In January 1965, Charles Whitman took up a temporary job Central Flight Lines. He also surveyed traffic as part of the team at the Texas Highways Department. At the time Kathleen was teaching biology. Family trouble began to haunt him again when his mother officially announced she was divorcing his father. Charles Whitman drove all the way to Florida to help his mother relocate to Austin, Texas. His little brother John also departed from Lake Worth but Patrick opted to remain with his father. Charles was under extreme pressure from his father to convince his mother to return to Lake Worth and move in back with him (Sillup).

The Killings
One day before Charles Whitman committed his infamous horrendous killings around the University of Texas his life was not out of the norm. He had previously purchased a cache of arms, binoculars and a knife claiming to be preparing to go on a hike hunting wild hogs (Lavergne 18). He drove as usual to pick up his wife from his place of work and took her to a matinee before meeting his mother for lunch. In the afternoon, they visited his friends Fran and John Morgan in the neighborhood and left at around five thirty so that Kathleen would make it to her night shift starting at six. At 6.45, Charles Whitman started typing his infamous suicide notes indicating that he could not understand the motivation behind the acts he was about to do and that he had been bombarded with many irrational thoughts (Sillup). He declared the true love he felt for his mother and wife and then started his mission.

Sometime after midnight, he suffocated and stabbed her mother fatally. When Kathleen returned from work, he crawled on her and stabbed her three times in the heart as she slept, killing her instantly. He then sat down and continued with his notes, noting down that he had just killed the two people he loved most in the world (Time). He then wrote an order directing that proceeds from his life insurance and estate be donated to a mental health research institution so that tragedies like the one he was committing would not occur in future (Time).

The following morning, he loaded his arms cache into a dolly and cheated his way up the bell tower. The first person to detect danger was the receptionist named Edna. After she asked if he had a workers identification card, he knocked her out with the butt of a rifle. Moments later, Whitman opened fire to two families who were making their way up the tower, killing two people instantly. At approximately 11.48 a.m. on August 1 1966, he fired his first shot from the bell towers outer deck (Time). What followed was a 96-minute ordeal in which he gunned down 14 people and wounded 34 more before police officers led by Martinez, Jerry Day and Houston McCoy and a hastily assembled force killed him (Lavergne 37).

Charles Whitmans Motivations
Charles Whitman was obviously mentally ill. He kept a personal diary titled The Daily Record of C. J. Whitman in which he openly admitted to himself that he was having a personality crisis (Lavergne 47)). He lamented in one of the entries that he was finding himself acting violently towards his wife Kathleen. Deep inside, a keen observer will see a deeply tormented man whose ambitions had not been fulfilled, a man who had not been fully appreciated by his father and family the way he would have wanted.

Charles Whitman was frustrated with life. Despite his being intellectually gifted, he did not manage to satisfy the requirements for the award of a degree in mechanical engineering from the University of Texas. He was therefore in the process of venting his anger out on people. Some of his closest friends, John and Francis, disclosed during the inquiry into the University of Texas tower shootings that Charles Whitman himself had admitted to them that he had physically assaulted his wife Kathleen on more than three occasions (Macleod).

When Charles Whitman joined the Marines, his conduct was unbecoming. It would be correct to conclude that he joined the army merely to exert his authority and independence from his demanding father (Lavergne 27). In his journal mentioned above, he once wrote concerning his contempt and disrespect for the marines. Being the genius he was, he pointed out what he perceived were the shortcomings of the marines. He was therefore not content with his position not only in the marines but in the society as a whole and his overwhelming energy and ego made him feel he could either have become a better person and made considerable input to the society, or his potential was not fully utilized (Macleod).

Another explanation for the outrageous crimes that Charles Whitman committed was the anomaly in his brain and central nervous system. Charles confirmed in his writings that he had seen several mental health experts. The mistake that happened was that almost all of them believed he had a psychological disorder and gave him prescription drugs to contain his runaway emotions of anger and confusion (Lavergne 61). The problem was that despite the fact that Charles Whitman had had a tumultuous childhood and early adulthood, he had a life threatening brain tumor that was responsible for his bizarre conduct. Records available from the university health services prove that he had sought professional help on several occasions. On many of these and to close associates, Charles Whitman remarked that it would be simpler for him to escalate the University of Texass bell tower and indiscriminately kill (Lavergne 62) people. It is very unfortunate that no one realized he actually meant was he said until it was too late and 14 people were already dead and many others were wounded.

Conclusion
Charles Whitman was a good man who wanted to make the most out of life. In his journal, which he filled daily during his stay in the marines and later, he often expressed his desire to become a better man than his father had been. He also loved his wife Kathleen dearly. The explanation to what made him commit those murders however emanated more from his brain tumor than from psychological effects of life experiences (Sillup). Later research shows that glioblastoma tumors prompt victims to react with progressive irritation and rage especially in the latter stages. Studies carried out indicated he was to die early due to this condition it is an explanation as to why he could not control his emotions and actions.

Many children often dread any visit to hospitals as they are mostly of the view that a hospital is a place where many injections take place and where there are many sick people. In the eyes of a child, a hospital has a bad smell, which is the distinctive disinfectant smell present in all hospitals. As study conducted specifically for children came to a conclusion that, to many of them the colors of hospital walls are dull and not cheerful at all. Although the many toys that are present at the pediatric units of many hospital are a huge relief for children in such a somber environment as they are a distraction to the solemnity of a hospital. Many children are also of the view that what happens in the treatment rooms in hospital is a punishment, mainly because of the injections that the nurses may possibly inject them.

In many cases, when a child is taken to hospital, he or she is usually scared and worried because he or she often feels that he or she has been taken to a very cold and harsh environment away from the loving and comfort atmosphere of home. A pediatric clinic that has toys, dolls, little plastic people, blocks, play dough and cheerful children books will make a huge impact on a child as he or she will become more at ease at the hospital (Rollins  Mahan, 2005). A child may feel withdrawn because of the new strangers he or she encounters at the hospital unlike the familiar faces he or she is used to seeing back at home (Thompson  Stanford, 1981). However, the hospital staffs are often friendly to the children and they wear cheerful smiles, thus the children will feel a little at ease after a while in the hospital. Children who are left in the pediatric wards to recuperate show signs of distress, as they feel lonely and abandoned in a strange place. Many children at the wards cry with relief after seeing their parents because most of them are so unhappy at the hospital and others rejected or ignored their parents because they are of view that their parents dumped them in the hospital (Quinton  Rutter, 2008)

The social environment of the hospital is quite different from other places as different people from all lifestyles surround it. There are the medical personnel, which is made up of the doctors, nurses and other medics, other patients and the family members and friends of the patients. The medical personnel are usually quite friendly to the children and this makes the children who are admitted in the wards to be at ease during the course of treatment. During visiting hours at the hospital, there are many visitors who mostly comprise of parents, other family members and friends. The presence of familiar people will make a child in the hospital feel comfortable and he or she will be able to enjoy the hospital experience more.

The presence of familiar people in a hospital where a child is admitted may have a huge impact on the child, as the child will feel loved, cherished, and more comfortable around the hospital (Cox et al, 2006). The child will face a new day at the hospital with anticipation as he or she will feel comfortable because of familiar people inside the hospital. Thus, the child will be comfortable. However, lack of familiar people in the hospital will make the child throw some temper tantrums as he or she will feel alone in the world with no one to show love or affection. For instance, absence of the parents of a child who is admitted in the ward may make a child feel depressed and the child may even throw a tantrum (Walker, 2007).

The hospital environment includes certain vocabulary that is easily misunderstood by children. For instance, the term injection, in the eye of a child is a violent and very painful act and most children feel like they are victims of this horrific act (Cox et al, 2006). Such terms may have a negative impact on a child as they often make a child to be psychologically affected and a big resistance from the child would be the reaction if there were a suggestion of a hospital visit from the parents.

There are many areas in hospitals where children are restricted to enter. For instance, children are generally restricted to enter the general ward because there are many chances that a child may contract a disease from this ward because there are many patients suffering from different ailments who have come to seek medical help (Quinton  Rutter, 2008). Other areas are such as the highly prone wards in the hospitals, which admit patients who are suffering from dangerous ailments like tuberculosis and other infectious diseases. Such restricted areas often pose high risks to children, as there immune system is not very strong like for an adult and they may be infected with some of the diseases that are present in these restricted areas (OHagan  Smitt, 1999). Furthermore, parents are usually advised to accompany their children at all times to avoid the children wondering in the hospital corridors alone, as they may gain access to the restricted areas and if this occurs it would have some detrimental effects on a child.

Recommended improvements
The pediatric unit in hospitals should have interiors that appeal to children. For instance, colorful paintings in the walls will make the pediatric unit look more appealing to the children. This will make the children feel more at ease on each visit to the hospital as well as those children who are already admitted (Browning, 2009)

The pediatric unit should consider designing a playroom, which can be a great place for children to play with their toys and this can make them forget the stressful routine in the hospitals. Play is reassuring and familiar to a child and it is often a way of sharing and communicating feelings and it can help a child to understand what hospital is all about (Walker, 2007). When a child plays with dolls, cars and other toys, this will keep a child in touch with the home the child is familiar with and is missing. Additionally, children benefit a lot from playing through the things that they are experiencing at the hospital, for instance, giving a doll an injection and taking teddies temperature.

Furthermore, to make a childs visit to the hospital easier, the parents should prepare the child psychologically for the hospital visit like four days prior to the hospital visit day (Quinton  Rutter, 2008). This ensures that the child is prepared well for the hospital, as in most cases many children view hospitals as punishment places, but with the necessary assurance from the parents they may not feel like this.

Moreover, the medical staff at the pediatric units should be more cheerful as this may relax the children admitted at this unit. A sense of warmth and great understanding can be a great relief to children who are admitted as well as those who are in for the routine check-ups (Balter  LeMonda, 2006).

The medical staff at the pediatric unit should communicate frequently with the children and assure them constantly that they will get better soon (Schaffer, 2003). This may make the child feel assured that their stay in the hospital will not be for long and that they will return to their homes soon. Children often like to hear this as the promise of home even uplifts their spirits.