Comparison of Electroconvulsive Therapy and Antidepressants

Comparison of Electroconvulsive Therapy and Antidepressants Brief 101151 INTRODUCTION Depression is one of the more common forms of mental illness. It has been estimated that approximately 9.5% of the population will suffer with depression at any one time (Robins and Regier 1990) and that 17% of people will suffer with depression at some point in their life (Blazer et al 1994). Defining depression is not a straight forward task. This is due to the fact that it can range from normal unhappiness through persistent and pervasive ways of feeling and thinking to psychosis (Hale 1997). Having said this, a number of different features which can be associated with depression have been identified by Hale (1997): Persistent low mood Loss of interest and enjoyment Reduced energy and diminished activity Poor concentration and attention Low self esteem and low confidence Ideas of guilt and unworthiness Bleak pessimistic views of the future Ideas or acts of self harm or suicide Disturbed sleep Diminished appetite It is also possible to distinguish between three major types of depression. The first form of depression is Dysthymia which involves long-term chronic depressive symptoms which do not necessarily disable the individual. The second form is Bipolar Disorder which involves the patient experiencing periods of mania and depression through cycles of mood change. The third and final category concerns Major Depression. The symptoms involved with this mental illness combine to ensure that it is difficult for the patient to work, study or to enjoy activities as well as them having difficulties regarding eating and sleeping patterns. It is this third and most serious form of depression which will be the focus of the following discussion. TREATMENT OF SEVERE DEPRESSION A number of different approaches to the treatment of depression have been taken which are based on a range of theoretical perspectives. These include approaches such as Cognitive Behavioural Therapy, Psychoanalysis and those based on increasing exercise levels. However, perhaps the most common treatment for depression involves the use of antidepressant drugs (American Psychiatric Association 1993) These include medications such as Tricyclic (which is cheap and effective but does have side effects which limit compliance), Selective Serotonin Up-Take Inhibitors (which has fewer side effects but less effective for disturbed sleep) and Monoamine (which, in rare cases, can be fatal when mixed with certain foods) Although antidepressants can be effective, research has indicated that they may not be the optimal solution. For example, Thomas et al (1982) conducted a study involving 115 participants who were randomly allocated to receive either a combination of antidepressants or a placebo. T he medication was found to have a significant effect but non-compliance was identified as a significant problem. It has been estimated that non-compliance regarding antidepressant drugs is between 20 and 59% (Johnson 1973 and Thomas et al 1982). Further research has also reported that patients who are suffering with depression are still at a significant risk of relapse or recurring symptoms even when they have been adhering to their medication programme for a long period of time (Grunhaus et al 1990). It may also be the case that medication is not suitable for all forms of depression. For example, Hale (1997) suggested that antidepressants may not be effective for psychotic depression. Therefore, as a result of the potential drawbacks of non-compliance, relapse and not being effective for all forms of depression, efforts have been made to identify other approaches for the treatment of severe depression. One of the most controversial treatment approaches is Electroconvulsive Therapy (ECT). It was first used in 1938 by Cerletti and Bini (Linington and Harris 1988). It involves sending an electrical current through the patient’s brain with the aim of stimulating the release of neurotransmitters which will ultimately improve the patient’s mood. ECT has obtained a somewhat negative reputation due to stories of bitten tongues and fractured bones and it is often seen as a form of punishment rather than treatment. However, reviews of its application have demonstrated that ECT does have significant benefits compared to simulated ECT, when all procedures are followed without an electrical current actually being given (The UK ECT Review Group 2003). Whenever one is making decisions regarding the use of any given treatments, one must consider the body of scientific evidence which has assessed the treatment’s efficacy and effectiveness. The following review will aim to consi der the research which has assessed the efficacy and effectiveness of ECT as a treatment for severe depression in order to determine its effectiveness with reference to the use of antidepressants. RESEARCH QUESTION Thus, the following review will aim to answer the question ‘Is ECT an effective treatment compared with antidepressants in cases of severe depression’. The methodology which was employed within this research will now be outlined. LITERATURE SEARCH A systematic review aims to integrate existing information from a comprehensive range of sources, utilising a scientific replicable approach, which gives a balanced view, hence minimising bias. It can also be stated that systematic reviews provide a means of integrating valid information from the research literature to provide a basis for rational decision making concerning the provision of healthcare. 2.1 SOURCES OF DATA The methodology employed within the research involved obtaining data from three key sources: Computerised searches, Manual searches, and the Internet. Each of these data sources will now be considered in more detail. 2.11 COMPUTERISED SEARCHES The methods used in this research will include a detailed computerised literature search. Multiple databases, both online and CD–Rom will be accessed to retrieve literature because they cite the majority of relevant texts. The computerised bibliographic databases are:- MEDLINE EMBASE CINAHL PSYCHINFO Biological Abstracts Cochrane SIGLE However because articles may not be correctly indexed within the computerised databases, other strategies will be applied in order to achieve a comprehensive search. 2.1.2 MANUAL SEARCHES A manual search will be performed to ensure that all relevant literature is accessed. The manual searches will include:- Books relevant to the topics from university libraries and web sites Inverse searching- by locating index terms of relevant journal articles and texts Systematically searching reference lists and bibliographies of relevant journal articles and texts 2.1.3 THE INTERNET The internet will provide a global perspective of the research topic and a searchable database of Internet files collected by a computer. Sites accessed will include:- Department of Health National Institute of Clinical Excellence English National Board of Nursing, Midwifery and Health Visiting Google British Medical Journal 2.2 IDENTIFICATION OF KEY WORDS A set of key words will be used within the literature search. Elements of the research question will be used to provide the search terms. Therefore, the words Electroconvulsive Therapy, Antidepressants, Depression, Effectiveness and Evaluation will all be used. 2.3 INCLUSION AND EXCLUSION CRITERIA To ensure that the more relevant research studies are identified, a set of inclusion and exclusion criteria will be utilised. In order to be included in this research the studies will need to relate to the evaluation of Electroconvulsive Therapy and relate to the treatment of depression. Furthermore, studies will be excluded if they are published before 1975 or if they are not available in English. DISCUSSION This review has identified literature which has focussed on assessing the effectiveness of ECT in comparison to antidepressants regarding the treatment of severe depression. In order to structure the discussion, the research will be analysed with reference to the benefits of ECT regarding relapse, patients who are drug-resistant and those with severe depression in particular. The potential drawbacks of ECT will then be briefly considered before overall conclusions are drawn regarding the research question. 3.1 RELAPSE Studies were located which highlighted the benefits of ECT regarding the reduction of relapse. For instance, Petrides et al (1994) reviewed the case histories of 33 patients who had been diagnosed with long term depression. A set of 21 patients were included in the study as a one year follow up report was available for analysis. Each of the participating patients had been taking antidepressants for a significant length of time but were still experiencing relapses of depression. After the delivery of ECT it was reported that the number of patients with depression who suffered relapses fell from a normal rate of 50% to 33% at the one year follow up. For the patients with delusional depression in particular, the relapse figure fell from a normal rate of 95% to 42%. Based on this research it would appear that ECT can be more effective than antidepressants in terms of reducing relapse rates. A more recent and relevant study was conducted by Gagne et al (2000) which also involved the retrospective reviewing of patients’ notes. Two groups of 29 matched participants were identified. The first group had only been taking antidepressants were as the second group had antidepressants along with ECT. At the two year follow up stage the relapse rates for those who had ECT was 52% compared to the 93% associated with those who only had medication. At the five year follow up stage, the relapse rate for the drug-only group had fallen slightly to 73% where as the ECT group had fallen dramatically to just 18%. The average survival rate of the ECT group was 6.9 years which was significantly longer than the 2.7 years for the drug-only group. Therefore the research considered in this section would lead one to conclude that ECT can be more effective than antidepressants alone in terms of reducing relapse rates. Having said this, it should be noted that these research projects involve d combining ECT with antidepressants rather than replacing them entirely. 3.2 MEDICATION RESISTANT PATIENTS Although antidepressants are effective for many patients with depression, there are some groups for whom it is less effective. Rabheru and Persad (1997) reviewed the literature which focused on assessing the effectiveness of ECT for patients who were found to be resistant to antidepressant medication. They found that the research evidence indicated that ECT could have significant benefits for medication resistant patients. These benefits were particularly relevant for elderly patients with depression. An important point to make here, however, was demonstrated by research conducted by Prudic et al (1996). They reported that the effectiveness of ECT may decline as the time for which the patient has suffered with severe depression increases. Therefore, the approach of using ECT when the patient has been found to be resistant to antidepressants may not be the optimal approach as the possible benefits of ECT may have been reduced. Therefore, this section has demonstrated that ECT could be beneficial for patients who have severe depression and have not been significantly helped by the use of antidepressants. However, it is important to note that the use of ECT may decline over time. 3.3 PATIENTS WITH SEVERE DEPRESSION Further research has indicated that ECT may well have particular benefits over antidepressants with regards to patients who have severe depression. Sobin et al (1996) conducted research to evaluate the effectiveness of ECT for patients with a range of levels of depression. They reported that 70% of the participants responded significantly as a result of the ECT and that significant improvements were made by those who had severe depression. Other research has also leant support for the assertion that ECT is particularly beneficial for patients with severe depressive symptoms, mood congruent delusions and those who are at prominent risk of committing suicide (Martin 1989, Schatzberg 1992, Persad 1990, Philibert et al 1995 and Fink et al 1996). It appears that the attributes of ECT are particularly suited to the treatment of people with severe depression. It may be that the more severe a person’s depressive symptoms are, the more drastic and severe the treatment approaches need t o be for them to be effective. CONCLUSIONS This review has considered research which has investigated whether ECT is effective in treating severe depression when compared to antidepressant drugs. Based on this research it can be concluded that ECT, when combined with antidepressants, does appear to significantly reduce patients’ relapse rates. It can also be said that the evidence supports the view that ECT can be effective for patients who have been found to be resistant to antidepressants. The third and final conclusion is that ECT appears to be particularly suited to patients with the more severe forms of depression. Having said this, some criticisms need to be acknowledged regarding this body of research. For instance, Rose et al (2003) highlighted three major drawbacks. Firstly 1 in 3 patients who are given ECT report persistent memory loss. Secondly, the research studies conducted by clinicians in this area report more positive results than those conducted by consumer agencies. This may be due to the selection of participants or the focus of the research questions. The third and final drawback outlined by Rose et al (2003) is that the studies which support ECT rarely assess the long term effects or cognitive functioning and the majority of them were conducted many years ago using small samples. The research is also limited because it mainly uses case studies (Thienhaus et al 1990), naturalistic studies (Aronson et al 1987) or retrospective reviews of patient notes (Stiebel 1995). Few randomly controlled trials were highlighted by this literature search. Such criticisms must be kept in mind when considering the effectiveness of ECT in comparison to antidepressants for treating severe depression. 5.0 IMPLICATIONS FOR PRACTICE Guidelines produced by the National Institute of Clinical Excellence, based on a review of Department of Health and Cochrane database research, recommends that ECT be used for rapid and short term improvements for patients with severe depression or who are at significant risk of suicide (Tharyan and Adams 2003). However, as highlighted by the Royal College of Psychiatrists (2003) in their response to these guidelines, the use of ECT may have a wider scope than this approach would suggest and the guidelines may ensure that patients who may benefit from ECT are not given the treatment. Further research in this area will provide a basis upon which to test the appropriateness of these guidelines and the current use of ECT. It would appear that ECT can have significant benefits for patients with severe depression but that more efforts need to be made to tackle the negative impressions which may be associated with this treatment such that it can become a more accepted approach. The main im plication of this review for practice is that ECT appears to have a significant role to play in the treatment of severe depression but that it is likely to be alongside the use of antidepressants rather than instead of them. This strategy will enable the most comprehensive treatment programme to be delivered to the patients and ensure that their chances of a full recovery are maximised. REFERENCES American Psychiatric Association (1993). Practice guidelines for major depressive disorder in adults. American Journal of Psychiatry; 150(suppl): 4. Aronson TA, Shukla S, and Hoff A: (1987) Continuation therapy after ECT for delusional depression: a naturalistic study of prophylactic treatments and relapse. Convulsive Therapy; 3:251–259[Medline] Blazer DG, Kessler RC, McGonagle KA, and (1994) Swartz MS. The prevalence and distribution of major depression in a national community sample: the national comorbidity survey. American Journal of Psychiatry;151:979-6. Gagne, G. G., Furman, M. J., Carpenter, L. L. and Price, L. H. (2000) Efficacy of continuation ECT and antidepressant drugs compared to antidepressants alone in depressed patients. American Journal of Psychiatry, 157, 1960-1963 Grunhaus L, Pande AC, and Haskett RF (1990) Full and abbreviated courses of maintenance electroconvulsive therapy. Convulsive Therapy; 6:130–138 Johnson DAW. (1973) Treatment of depression in general practice. British Medical Journal; ii: 18-20. Linington, A. and Harris, B. (1988) Fifty years of electro-convulsive therapy. British Medical Journal, 297, 1354-1355 Martin BA (1989) Electroconvulsive therapy for depression in general psychiatric practice. Psychiatric Journal of the University of Ottawa; 14:413–417 National Institute for Clinical Excellence (2003). Guidance on the use of electroconvulsive therapy. London: NICE, 2003. www.nice.org.uk/pdf/59ectfullguidance.pdf (accessed 9 Jun 2003). Persad E: (1990) Electroconvulsive therapy in depression. Canadian Journal of Psychiatry; 35:175–182[Medline] Petrides G, Dhossche D, Fink M, and Francis A: (1994) Continuation ECT: relapse prevention in affective disorders. Convulsive Therapy; 10:189–194 Philibert RA, Richards L, Lynch CF, and Winokur G: (1995) Effect of ECT on mortality and clinical outcome in geriatric unipolar depression. Journal of Clinical Psychiatry; 56:390–394[Medline] Prudic J, Haskett RF, Mulsant B, Malone KM, Pettinati HM, Stephens S, et al. (1996) Resistance to antidepressant medication and short-term clinical response to ECT. American Journal of Psychiatry;153:985-92. Rabheru K, and Persad E: (1997) A review of continuation and maintenance electroconvulsive therapy. Canadian Journal of Psychiatry; 42:476–484 Robins LN, Regier DA (Eds) (1990). Psychiatric Disorders in America, The Epidemiologic Catchment Area Study,; New York: The Free Press. Rose D, Wykes T, Leese M, Bindman J, and Fleischmann P. (2003) Patients perspectives on electroconvulsive therapy: systematic review. British Medical Journal;326: 1363-5.[Abstract/Free FullText] Sackeim HA (1994) Continuation therapy following ECT: directions for future research. Psychopharmacology Bulletin; 30:501–521 Schatzberg AF: (1992) Recent developments in the acute somatic treatment of major depression. Journal of Clinical Psychiatry; 53(Mar suppl):20–25 Sobin C, Prudic J, Devanand DP, Nobler MS, and Sackeim HA. (1996) Who responds to electroconvulsive therapy? British Journal of Psychiatry;169:322-8. Stiebel VG: (1995) Maintenance electroconvulsive therapy for chronically mentally ill patients: a case series. Psychiatric Service; 46:265–268 Tharyan P, and Adams` `C`E (2003) Electroconvulsive therapy for schizophrenia. Cochrane Schizophrenia Group. Cochrane Database Systematic Review;(1): CD000076 The UK ECT Review Group (2003) . Electroconvulsive therapy: systematic review and meta-analysis of efficacy and safety in depressive disorders. Lancet;361: 799-808 Thienhaus OJ, Margletta S, and Bennett JA: (1990) A study of the clinical efficacy of maintenance ECT. Journal of Clinical Psychiatry; 51:141–144 Thompson J, Rankin H, Ashcroft GW, Yates CM, McQueen JK, and Cummings SW. (1982) The treatment of depression in general practice: a comparison of L-tryptophan, amitriptyline and a combination of L-tryptophan and amitriptyline with placebo. Psychological Medicine; 12: 741-751[Medline].

Change In The Things They Carried Essay examples -- Tim OBrien OBrien

Change In The Things They Carried a war novel by Tim O'Brien, we are told many short stories compiled to make a whole. I want to emphasis on the importance of the chapter "Sweetheart of the Song Tra Bong". In this chapter we are introduced to the character Mary Anne. She shows the changing power of Vietnam, that a sweet innocent young girl can come into this land and be forever consumed by her surroundings. The speaker show us this through character action, character description, dialogue and metaphor; this enhances the literary work by showing us that the soldiers will always be a part of Vietnam no matter how hard they try to get away from it. Mary Anne was a young sweet innocent girl unaffected by the war at first. The speaker shows us with character description from what she was wearing when she arrived. "This cute blonde just a kid, just barely out of high schoolÂ…white culottes and this sexy pink sweater."(O'Brien 90) Her "pink sweater" is a symbol for innocence, the color pink is associated with innocence; "barely out of high school" can also imply her innocence. The end of high school is the beginning of a new world for most. Thus meaning that she has her whole life in front of her. That she is just starting life. In this next quote you will see that she had the rest of her life planned out or so she thought. "Mary Anne Bell and Mark Fossie had been sweethearts since grammar school. From the sixth grade on they had known for a fact that they would get marriedÂ…that was the plan. They were very much in love, full of dreams, and in the ordinary flow of their lives the whole scenario might well have come true." (94) The speaker placed this quote to foreshadow Mary Anne's change. "Ordinary flow of their lives the whole sc... ... truth. This story enhances the literary work for it shows what can happen if you embrace a culture while surrounded by others who are just simply living off the land not being courteous to those who live on it. Her love for this land changed her forever, She is not the same sweet innocent Mary Anne who came off of that helicopter, and she is now one with Vietnam. This is a metaphor for what took place in the lives of soldiers, they go there expecting to just "hump" along but get consumed by the land. It forever changes them so that they will never be the same again. There minds are forever warped, they will go in as one person and leave another. The speaker uses Mary Anne as an accelerated version of a soldier's life to make a dramatic effect. She is to show how much a man changes after war, no matter how hard they try to deny it. The war has became a part of them.

Bp Case

1. The aspects of BP’s ethical culture that could have contributed to the Gulf Coast oil spill disaster include: * The company tried to assure concerned stakeholders that it took environmental concerns seriously, but BP’s actions have not always concided with its words. BP has engaged in numerous instances of questionable behavior including fraud, environmental, and ethical transgressions clearly demonstrate that the company has a history of disregarding the well-being of stakeholders.The company has claimed to be an ethical company, concerned with stakeholder well-being, but its many violations tell a different story. * BP’s code of conduct was not sufficient to prevent a man made environmental disaster on an unprecedented scale. Apparently, BP’s code did not effectively address specific high risk activities within the scope of daily operations. * An investigation implies that BP cut short procedures and quality testing of the pipe (tests that are meant t o detect has in the well).Also, BP used a less costly well design that some investigators deemed â€Å"risky†. Installation of this design is easier and costs are lower. Although, BP didn’t break any laws by using this design, they ignored safer alternatives (to save money) that might have prevented, or at least hindered, the accident. * BP admitted that they had ignored several procedures required by the Clean Air Act for ensuring mechanical integrity and a safe startup between 1999 until the explosion in 2005 that killed 15 employees and injured another 170 people.The explosion was the result of a leak of hydrocarbon liquid, and vapor. Another leak that happened in 2006 occurred after BP failed to respond to numerous red flags. One of these flags consisted of a dangerous corrosion in its pipes that had gone unchecked for more than a decade. * To narrow this entire question up, BP took shortcuts in their productions to cut their costs, and ignored defaults, regular ro utine cleanings, and maintenance of the rigs causing explosions and leaks, and people getting killed, harmed, or injured. . Yes, BP engaged in purposeful avoidance of risk management. * Some suggest that BP cut corners in risk management to save time and money. * BP had a responsibility to ensure that appropriate precautions were taken to prevent a disaster, but they failed to meet their responsibilities. For example, one technician that worked on the oil rig accused BP of willful negligence. He claims that BP did in fact have knowledge that the rig’s blowout preventer was leaking weeks prior to the explosion, but did not halt the production. BP’s contingency plan in case of a disaster was inadequate. It contained many important inaccuracies. For example, one of the wildlife experts listed as an emergency responder had been dead since 2005. Another example, is that the contingency plan estimated that if a oil spill should occur, that the company would be able to recove r about 500,000 barrels of oil per day, when in reality it took BP months to just contain the leak, at a spill rate of much less than listed in their plan.The inaccuracies of BP’s contingency plan shows how unprepared the company was for a disaster like the Deep Water Horizon spill. 3. I think that in order for BP to rebuild their reputation and manage the risks associated with offshore drilling, they should not take shortcuts or cut corners to save time or money. They should commit to a socially responsible approach and stakeholder engagement. They should have safety organizations in place. They should follow safety rules and regulations. Conduct better start up procedures.

Animal Cruelty and Circuses

Most accusations of animal cruelty in circuses focus on the  elephants, but from an animal rights perspective, no animals should be forced to perform tricks in order to earn money for their human captors. Circuses and Animal Rights The animal rights position is that animals have a right to be free of human use and exploitation. In a vegan world, animals would interact with humans when and if they want to, not because they are chained to a stake or trapped in a cage. Animal rights is not about bigger cages or more humane training methods; its about not using or exploiting animals for food, clothing, or entertainment. Attention has focused on elephants because they are considered by many to be highly intelligent, are the largest circus animals, may be the most abused,  and arguably suffer more in captivity than smaller animals. However, animal rights is not about  ranking or quantifying suffering, because all sentient beings deserve to be free. Circuses and Animal Welfare The animal welfare position  is that humans have a right to use animals, but cannot harm animals gratuitously and must treat them humanely. What is considered humane varies greatly. Many animal welfare advocates consider fur, foie gras, and cosmetics testing  to be frivolous uses of animals, with too much animal suffering and not much benefit to humans. Some animal welfare advocates would say that eating meat is morally acceptable as long as the animals were raised and slaughtered humanely.   Regarding circuses, some animal welfare advocates would support keeping animals in circuses as long as training methods are not too cruel. Los Angeles recently banned the use of bullhooks, a sharp tool that is used as punishment in training elephants.  Many would support a ban on wild or exotic animals in circuses. Circus Cruelty Animals in circuses are often beaten, shocked,  kicked, or cruelly confined in order to train them to be obedient and do tricks. With elephants, the abuse begins when they are babies to break their spirits. All four of the baby elephants legs are chained or tied for up to 23 hours per day. While they are chained, they are beaten and shocked with electric prods. It can take up to six months before they learn that struggling is futile. The abuse continues into adulthood, and they are never free of the bullhooks that puncture their skin. Bloody wounds are covered with makeup to conceal them from the public. Some argue that elephants  must love performing because you cant bully such a large animal into doing tricks, but with the weapons at their disposal and years of physical abuse, elephant trainers can usually beat them into submission.  There are, however, tragic cases where the elephants rampaged and/or killed their tormentors, leading to the elephants being put down.   Elephants are not the only victims of abuse in circuses. According to Big Cat Rescue, lions and tigers also suffer at the hands of their trainers:  Often the cats are beaten, starved, and confined for long periods of time in order to get them to cooperate with what the trainers want.  And life on the road means that most of a cat’s life is spent in a circus wagon in the back of a semi-truck or in a crowded, stinking box car on a train or barge. An investigation of one circus by Animal Defenders International found that the dancing bears spend around 90% of their time shut in their cages inside a trailer. Their time outside these miserable prison cells generally averages just 10 minutes a day on weekdays and 20 minutes on weekends. ADIs video shows one bear desperately circling a small steel cage measuring about 31/2 feet wide, by 6ft deep and about 8ft high. The steel floor of this barren cage is covered in just a scattering of sawdust. With horses, dogs, and other domesticated animals, training and confinement may not be as torturous, but any time an animal is used commercially, the animals well-being is not the first priority.   Even if the circuses did not engage in cruel training or extreme confinement methods (zoos generally do not engage in cruel training or extreme confinement, but still violate the animals rights), animal rights advocates would oppose the use of animals in circuses because of breeding, buying selling and confining animals violates their rights. Circus Animals and the  Law Bolivia was the first country in the world to ban animals in circuses. China and Greece followed. The United Kingdom has banned the use of wild animals in circuses, but allows domesticated animals to be used. In the United States, the federal Traveling Exotic Animal Protection Act would ban the use of nonhuman primates, elephants, lions, tigers, and other species in circuses, but has not been passed yet. While no U.S. states have banned animals in circuses,  at least seventeen towns  have banned them. The welfare of the animals in circuses in the U.S. is governed by the Animal Welfare Act, which offers only the bare minimum of protection and does not prohibit the use of bullhooks or electric prods. Other laws, like the Endangered Species Act and Marine Mammal Protection Act  protect certain animals, such as elephants and sea lions. A lawsuit against Ringling Brothers was dismissed based on a finding that  plaintiffs did not have standing; the court did not rule on the cruelty allegations. The Solution While some animal advocates want to regulate the use of animals in circuses, circuses with animals will never be considered completely cruelty-free. Also, some advocates believe that a ban on bullhooks just causes the practice to remain backstage and does little to help the animals.   The solution is to go vegan, boycott circuses with animals, and support animal-free circuses, such as Cirque du Soleil  and Cirque Dreams.