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Effects of Exercise on Depression During Pregnancy and Postpartum: A Review

Beth A. Lewis and Betsy F. Kennedy AMERICAN JOURNAL OF LIFESTYLE MEDICINE 2011 5: 370 DOI: 10.1177/1559827610392891 The online version of this article can be found at: http://ajl.sagepub.com/content/5/4/370

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American Journal of Lifestyle Medicine

July Aug 2011

Beth A. Lewis, PhD, and Betsy F. Kennedy, MA

Effects of Exercise on Depression During Pregnancy and Postpartum: A Review

Abstract: Approximately 13% of pregnant women and 10% to 15% of postpartum women report depression. Research indicates that exercise is efficacious for treating depression among adults in general; however, less is known regarding the efficacy of exercise for treating depression during pregnancy and the postpartum phase. In this article, the authors review the available studies examining the effect of exercise on mood and depressive symptoms during pregnancy and postpartum. The authors identified 4 studies examining the effect of exercise on mood during pregnancy and 9 studies examining exercise and depression in the postpartum phase. A majority of these studies indicated that exercise may be beneficial for improving mood; however, the studies had significant limitations, including lack of randomization, small sample sizes, and lack of control for contact time. Additional research is needed to better understand the effect of exercise on depression during pregnancy and the postpartum phase. Taken together, because of the potential benefits of exercise on mood during pregnancy and postpartum and the general health benefits of exercise, health care providers should encourage their healthy pregnant and postpartum patients to exercise. The authors provide practical suggestions for depression screening and exercise counseling for pregnant and postpartum women. Keywords: pregnancy; postpartum; exercise; physical activity; depression health problem.1 Research indicates that 18.4% of pregnant women experience depressive symptoms and approximately 12.7% experience a major depressive episode during pregnancy.2 The rate of depression is higher during the first trimester of pregnancy compared with the

Exercise may also be preferred relative to antidepressant medication, given that many women discontinue antidepressant medication during pregnancy, and women may be reluctant to use antidepressant medication if breastfeeding during the postpartum phase.
Depression During Pregnancy Depression during pregnancy is relatively common and is a significant public second and third trimesters.2 Depression during pregnancy is a significant predictor of postpartum depression.3 High levels of stress and anxiety related to depression during pregnancy are also

DOI: 10.1177/1559827610392891. Manuscript received October 15, 2009; revised March 9, 2010; accepted April 20, 2010. From the School of Kinesiology, University of Minnesota, Minneapolis, Minnesota. Address correspondence to Beth A. Lewis, PhD, School of Kinesiology, University of Minnesota, 1900 University Avenue SE, 209 Cooke Hall, Minneapolis, MN 55455; e-mail: blewis@umn.edu. For reprints and permissions queries, please visit SAGEs Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright 2011 The Author(s)
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related to premature labor and low birth weight.4 Additionally, researchers have linked depression during pregnancy to lower neuromotor performance in the newborn.5 According to a meta-analysis, several types of psychosocial interventions are efficacious for treating depression during pregnancy, including brief interpersonal therapy and education.6 Similarly, a recent Cochrane review indicates strong support for the efficacy of psychosocial interventions for postpartum depression.7 The 10 studies included in the review indicated that the psychosocial intervention reduced levels of depressive symptoms when compared with usual care. The psychosocial interventions varied in content and included interpersonal, cognitivebehavioral treatment; nondirected counseling; and telephone-based support. Antidepressants are effective for treating general depression8,9; however, the efficacy of antidepressants specifically used during pregnancy has not been well studied.6 In a nonrandomized longitudinal study, Cohen and colleagues10 examined the effect of discontinuing antidepressant medication during pregnancy. Results indicated that 65 of the 201 women discontinued their antidepressant medication and another 34 reduced their dose. Furthermore, 26% of women who maintained their use of antidepressant medication during pregnancy experienced a relapse of depression during pregnancy, whereas 68% who discontinued their antidepressant medication relapsed. Although definitive conclusions cannot be made given the lack of a randomized controlled design, this study suggests that there is a need for alternative therapies for depression during pregnancy. There are potential ethical reasons for the lack of randomized trials examining the efficacy of antidepressant medication. For example, research indicates that using antidepressants during pregnancy may be associated with shorter gestation and birth malformations in the fetus.11 Therefore, it may be unethical to provide antidepressant medication to pregnant women, given their potential for inducing birth defects. However, it is important to note that the research

linking antidepressants to birth defects is not conclusive, given that several studies did not control for various confounding factors.11 Another potential ethical issue is that if antidepressant medications are effective during pregnancy, it may be unethical to withhold treatment from pregnant women randomly assigned to a placebo condition. A final ethical consideration is the dose of medication. To ensure safety of the fetus, clinicians frequently decrease the dose of antidepressant medication.12 However, pregnant women typically require an increased dose of the antidepressant medication to reach therapeutic levels because of changes in plasma volume and increases in hepatic metabolism and renal clearance.13,14 Therefore, this suggests that antidepressant medication may not be as effective during pregnancy if the medication dose is maintained at the same or lower levels. Depression During Postpartum Phase It is estimated that approximately 30% to 75% of new mothers experience baby blues.15 Baby blues can involve a mild mood disturbance, irritability, sleep and appetite disturbance, tearfulness, and generalized anxiety.15 Baby blues typically occur within the first few days following childbirth and last from a few days to up to 2 weeks. Treatment is typically not required for baby blues. Postpartum depression, on the other hand, usually occurs during the first 6 weeks after delivery but can occur up to 6 months following childbirth.15 Unlike the baby blues, postpartum depression often does require treatment.15 To meet the diagnostic criteria for depression, depressive symptoms must interfere with the daily functioning of the mother and last for at least 2 weeks.16 Common symptoms include feelings of despondency, guilt, loss of appetite, sleep disturbance, tearfulness, inability to cope with the infant, fatigue, irritability, difficulty concentrating, and suicidal ideation.17 Recent estimates indicate that 10% to 15% of postpartum women experience depression.1,2 However, there has been variabil-

ity across studies, with 1 study reporting a rate as high as 36%.18 Research indicates that 30% to 50% of women who have depressive symptoms in the early part of the postpartum period continue to have depressive symptoms during the first year postpartum.19,20 Risk factors for postpartum depression include low education, low income, young maternal age, and not being employed full-time.21 Postpartum depression can have a profound effect on both the mother and newborn. Specifically, research indicates that negative consequences of postpartum depression include poor functional status of the mother,22 increased risk of depression in the future,23 poor infantchild bond,24,25 difficulty caring for the newborn,22 and adverse effect on the significant other.26,27 Unfortunately, few women with postpartum depression seek treatment.28 Preliminary evidence does indicate that antidepressants may be effective for treating depression during the postpartum phase.29 For example, 1 study indicated that fluoxetine was equally effective relative to a cognitive-behavioral intervention for postpartum depression.30 Similarly, Misri and colleagues31 found that paroxetine was equally effective relative to a cognitive behavioral intervention plus paroxetine. Limitations of this study included a small sample size and no placebo control group. A general limitation of using antidepressants during the postpartum period is that mothers who are breastfeeding may be reluctant to take antidepressant medication.32,33 Additional research is needed to better understand both the safety and effectiveness of antidepressants for the treatment of depression during the postpartum phase. Exercise and Depression One potential intervention that may be effective for treating depression during pregnancy and the postpartum phase is exercise. Exercise may be a viable alternative to psychotherapy given that cost, child care, and transportation constraints may be potential barriers to psychotherapy. Exercise may also be preferred relative to antidepressant medication, given
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that many women discontinue antidepressant medication during pregnancy, and women may be reluctant to use antidepressant medication if breastfeeding during the postpartum phase.32,33 Research indicates that exercise is effective for treating major depression in adults34,35and, therefore, could also be effective during pregnancy and postpartum. For example, 1 study found that exercise, sertraline, and exercise plus sertraline were equally efficacious in reducing depressive symptoms both at the end of treatment36 and at follow-up.37 In this same study, participants who maintained their exercise following treatment were less likely to be depressed at follow-up.37 Dunn and colleagues35 conducted another randomized trial, which found that individuals who exercised at least 5 days per week for 30 minutes or more each session experienced reductions in their mild or moderate symptoms of depression. A final study conducted by Blumenthal and colleagues34 found that among individuals with a major depressive disorder, both sertraline and an exercise intervention were more efficacious than a placebo for reducing depressive symptoms. The behavioral activation of exercise may serve as the mechanism for reducing depressive symptoms. Specific physiological mechanisms may influence the effect of exercise on depression.38 For example, it has been hypothesized that dysregulation in the central monoamine system may play a role in depression. Exercise may reduce depressive symptoms by correcting this imbalance in the central monoamine system. Similarly, depression has been linked to imbalances of the hypothalamicpituitaryadrenal axis, and exercise is linked to an attenuation of the response to stress by this axis. More research is needed to better understand the exact physiological mechanism underlying the effect of exercise on depression. Purpose of This Article The purpose of this article is to review the literature examining the effect of exercise on depression during pregnancy and the postpartum phase. Our review
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expands on the recent review conducted by Daley et al39 by evaluating the pregnancy literature in addition to the postpartum literature. Additionally, unlike the Daley et al article, we will include observational studies as well as randomized controlled trials. We will also provide practical suggestions for screening and managing pregnant and postpartum women who have depression. Overview of Literature Review Several sources were used when conducting the literature search for this article, including Pubmed, PsycINFO, CINAHL, and personal communications. A total of 320 articles were found through the literature search using the keywords exercise, or physical activity and depression and pregnancy, or postpartum. Articles that did not focus on how exercise during pregnancy or postpartum affects depression were excluded. They were also excluded if they (1) examined the relationship between postpartum depression and weight loss, (2) focused on psychobiology only, (3) examined exercise prior to pregnancy, and (4) were not written in English. Additionally, 1 study examining pregnancy during adolescence was excluded, given that this population is coping with different stressors from those of adult women. This article will focus on the remaining 13 articles. Effect of Exercise on Mood During Pregnancy We identified 4 articles examining the effect of exercise on depression during pregnancy, and they are summarized in Table 1. Specifically, Polman and colleagues40 evaluated the effect of 1 session of exercise on mood among pregnant women. The sample consisted of 66 pregnant women between the ages of 22 and 41 years in their second or third trimester of pregnancy. Participants were assigned to 1 of the following 4 groups: (1) aquanatal exercise class, (2) studio exercise class, (3) parent craft class led by a midwife at a hospital, or (4) a control group that did not exercise or participate in the parent craft class.

The exercise and parent craft classes lasted 45 to 50 minutes. Participants took the Profile of Mood State Scale (POMS) to assess their mood 10 minutes prior to the class and immediately after the class. Results indicated that the exercise classes led to improvements in mood relative to the parent class. The major limitation of this study is that participants were not randomized to the various conditions. Furthermore, participants in the exercise classes reported higher exercise levels than participants in the other conditions, which is particularly problematic given the lack of randomization. Another limitation is that it is unclear how long the effect of the intervention persisted. In a similar study, Koltyn41 examined the effect of an exercise program on mood and anxiety among 20 pregnant women. Participants either participated in an exercise session or an informational meeting, both lasting 90 minutes. The exercise session consisted of a 15-minute warm-up, 45 minutes of exercise (ie, walking, stationary cycling, and rowing), 15 minutes of floor exercises, and 15 minutes of cool-down. Mood was assessed using the POMS, and anxiety was assessed using the State-Trait Anxiety Inventory (STAI). Both questionnaires were administered before and after the sessions for both groups. Results indicated that the exercise session led to improvements in mood and reduced anxiety relative to the control group. Limitations of this study included the small sample size and lack of randomization to the 2 conditions. Another study used an observational design to examine the relationship between leisure-time exercise and psychological well-being.42 Participants (n = 180) were recruited in their first trimester of pregnancy and completed questionnaires throughout their pregnancy. The Lubin Depression Adjective Checklist Form C was used to assess depression, and the STAI was used to assess anxiety. Exercise was assessed using a structured interview examining frequency and duration of exercise. Participants who exercised during the first and second trimesters of pregnancy reported fewer depressive

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Table 1. Effect of Exercise on Mood During Pregnancy Study Da Costa et al42 Participants 180 Pregnant women Exercise and Assessment Structured interviews during each trimester and questionnaires completed each month 90-Minute aerobic exercise session or 90-minute information session for 6 sessions; POMS assessed mood Aqua class, studio class, parent craft class, or control group; POMS assessed mood 7-Day Physical Activity Recall Interview, accelerometer; POMS assessed mood Study Design Observational Findings Exercise resulted in fewer depressive symptoms

Koltyn41

20 White/ pregnant women 66 Pregnant women

Nonrandomized group comparison

State-anxiety and depressive symptoms lower in exercise group Exercise class had higher mood scores

Polman et al40

Nonrandomized group comparison

Poudevigne and OConnor43

12 Pregnant women

Observational

No correlation between physical activity and mood

Abbreviation: POMS, Prole of Mood States Scale.

symptoms than participants who did not exercise. This relationship was not found during the third trimester. Participants who exercised also reported lower anxiety levels than participants who did not exercise. This result was found for all 3 trimesters of pregnancy. The limitation of this study is that exercise was assessed using a self-report measure. Additionally, the study was observational and therefore causation cannot be inferred. In other words, it is possible that participants who experienced lower depression and anxiety were more likely to exercise or vice versa. Poudevigne and OConnor43 examined the relationship between mood and physical activity among pregnant women (n = 12). Participants completed the 7-Day Physical Activity Recall Interview, wore an accelerometer to objectively measure physical activity, and completed the POMS. Results indicated no significant correlation between physical activity and mood. The major limitation of this study is the small sample size.

Effect of Exercise on Postpartum Depression We identified 9 studies examining the effect of exercise on postpartum depression, which are summarized in Table 2. Koltyn and Schultes (1997)44 examined the effect of 1 session of exercise on mood among women who had delivered a baby within the previous year (n = 20). Participants were randomly assigned to complete 1 exercise session or a quiet rest session. Participants completed the STAI and the POMS before and after the session. The exercise session consisted of 60 minutes of low-impact aerobic activity at 60% to 70% maximal heart rate reserve. Results indicated that both anxiety and depression decreased following the exercise and rest sessions; however, exercise was related to a decrease in total mood disturbance. One major limitation of this study is that it was laboratory based and may not generalize to a real-world setting. Additionally, the sample size was small, and it is unclear what the effect of

multiple exercise sessions would be on mood. Ko and colleagues45 examined the effect of multiple exercise sessions on depressive symptoms among postpartum Taiwanese women. Participants who were willing to participate in the lowintensity exercise program (ie, Pilates, yoga movements, and music at 50% to 60% maximal heart rate) were assigned to the exercise group (n = 31). All other individuals were assigned to the control group (n = 30). The exercise program lasted 1 hour, 3 days per week. Participants completed the questionnaires after completing 6 classes. Depression was assessed using the Chinese version of the Center for Epidemiological Studies Depression Scale. There were no differences between groups on depressive symptoms. Limitations of the study included lack of randomization, small sample size, and a short-term follow-up assessment (ie, 2 months). Another study examined the effect of exercise on physical and mental fatigue
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Table 2. Effect of Exercise on Mood During the Postpartum Phase Study

Abraham et al52

Participants
181 Healthy women who had given birth the week before

Exercise and Assessment

Interview and questionnaire in postnatal week, which retrospectively assessed health behaviors during pregnancy 12-Week pram walking plus social support sessions; EPDS assessed depression Two 40-minute pram-walking sessions plus 1 session on own per week for 12 weeks; EPDS assessed depression Two motivational sessions, including walking and pedometers; 2 support telephone calls (lasted 12 weeks); EPDS assessed depression Exercise intervention for 12 weeks (met with exercise physiologist) or control group; questionnaire assessed outcome variables Participants completed survey items examining exercise and mood

Study Design
Observational

Findings
Exercising for body shape and weight reasons in early pregnancy related to less depressive symptoms during postpartum Pram walking plus social support group had greater reduction in depressive symptoms Pram-walking group had greater reduction in depressive symptoms

Armstrong and Edwards48 Armstrong and Edwards49

20 Postpartum women who screened positive for depression 24 Women who had given birth during the previous 12 months and screened positive for depression 38 Postpartum women (1 year or less) who were at risk of or diagnosed with postpartum depression 88 Postpartum sedentary women experiencing symptoms of postpartum depression 2169 Women who had given birth and had participated in a large overall survey 80 Postpartum Taiwanese women who had a high risk of postpartum depression 61 Postpartum Taiwanese women

Randomized to pram walking program plus social support or control Randomized to pram-walking program or social support control Randomized to exercise or usual care

Daley et al50

No signicant differences between groups on depression (no exercise differences between the groups)

Dritsa et al46

Randomized to exercise or control group

Exercise intervention arm had less physical fatigue; effect on depressive symptoms not reported Exercise before and during last trimester of pregnancy had a positive effect on interest and pleasure but no effect on depressed mood Participants in exercise group had lower depression scores

Ersek et al51

Observational

Heh et al47

Exercised 3 times a week for 3 months in hospital and at home with exercise CD; EPDS assessed depression Participated in 6 low-intensity exercise sessions in 3 weeks; CES-D assessed depression Exercise was one 60-minute bout; STAI assessed anxiety, and POMS assessed depression

Randomized to exercise or control group Nonrandomized group comparison

Ko et al45

No signicant differences between groups on depression scores Anxiety and depression decreased following exercise and rest sessions; exercise related to less total mood disturbance

Koltyn and Schultes44

20 Women who had delivered a baby within the past year

Participants randomly assigned to exercise or rest session

Abbreviations: EPDS, Edinburgh Postnatal Depression Scale; CES-D, Center for Epidemiological Studies Depression Scale; STAI, State-Trait Anxiety Inventory; POMS, Prole of Mood State Scale.

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among women experiencing postpartum depressive symptoms.46 Participants who were 4 to 38 weeks postpartum (n = 88) and reported depressive symptoms were randomly assigned to an exercise intervention or control. Participants in the exercise intervention met with an exercise physiologist 4 times over the 12-week intervention. The 90-minute session included an overview of the benefits of exercise, an exercise prescription, and a supervised exercise session. Participants were also given a heart rate monitor to assess their exercise at home and logged their exercise. A maximal graded exercise stress test using a treadmill assessed cardiovascular fitness. Participants in the exercise group reported an average of 124 minutes of exercise per week. Participants in the control group completed exercise questions monthly during the 12-week intervention phase. The exercise arm reported a significant decrease in physical fatigue relative to the control group at both posttreatment and 3 months following treatment. There were no differences for mental fatigue at posttreatment, but marginal significant differences between the intervention and group arms (with the intervention arm reporting greater decreases in mental fatigue) were observed at the 3-month follow-up. The direct effect of the intervention on depressive symptoms was not reported. There are several strengths of this study, including a randomized design and an objective assessment of exercise. One limitation is that the control arm did not control for contact time, so it is possible that the contact received by the intervention arm influenced the findings relative to the control arm. Heh and colleagues47 examined the effect of exercise on the severity of postpartum depression by randomly assigning 80 postpartum Taiwanese women to an exercise or control condition. Only participants who scored 10 or higher on the Edinburgh Postnatal Depression Scale (EPDS) were included in the study. The exercise arm consisted of once a week supervised exercise sessions lasting 1 hour and 2 sessions per week of homebased exercise with a CD. Participants were telephoned once per week to

remind them to complete their homebased exercise sessions. Adherence to exercise was high, in that only 3 women in the exercise arm did not complete the home-based exercise sessions. Both the exercise and control arms were given a 3-page postpartum depression booklet and were asked to log their exercise each day. Results indicated that women in the exercise arm significantly reduced their depressive symptoms score relative to the control group at 5 months. Strengths of this study included the randomized design and high adherence to exercise. Limitations included a short-term follow-up, using a non-diagnostic tool to assess depression, and self-report of exercise behavior. Armstrong and Edwards48 examined the effect of a walking program on postpartum depression among postpartum women who scored 12 or more on the EPDS. Participants were randomized to either a 12-week group-based walking program plus social support or a control group. The exercise group reported greater decreases in depressive symptoms relative to the control group at both 6 and 12 weeks. One major limitation to this study is that it is unclear whether exercise or social support accounts for the effect. Furthermore, the control group did not control for contact time. To address these limitations, the researchers conducted another trial in which Australian women (n = 24) who were 6 weeks to 18 months postpartum and who scored 12 or more on the EPDS were randomly assigned to a pram-walking program or to a social support control.49 The pram-walking program lasted 12 weeks and consisted of 2 group walking sessions per week lasting 40 minutes. Participants were also instructed to walk once per week on their own time. The social support control group met once per week for 90 minutes during the 12 weeks. This group met with the other mothers in the study and their children and did not exercise. Participants in the pram-walking group exhibited improvements in their depressive symptoms relative to the control group at the end of treatment. Strengths of this study included the random assignment

and control for contact time. Limitations included a small sample size and the fact that depression was not assessed using a structured interview. Daley and colleagues50 examined the feasibility of an exercise intervention for the treatment of postpartum depression. Participants (n = 38) were women who had a child less than 1 year of age and who were either at risk of or diagnosed with postpartum depression. Participants were randomized to a 12-week exercise condition or usual care. The exercise condition consisted of 2 one-on-one consulting sessions focusing on increasing motivation to exercise, coping with barriers, setting goals, increasing self-efficacy, and relapse prevention. The session also included a walking session, and participants were given pedometers. Participants also received 2 support telephone calls. Women in the usual care arm were told not to change their exercise behavior and were provided an exercise consultation session at the end of the 12-week treatment phase. Depression was assessed using the Edinburgh Postnatal Depression survey at 12 weeks (ie, posttreatment). Regarding feasibility, the authors were successful in recruiting 38 postpartum women; however, response rates were low. Additionally, the authors were unsuccessful in helping the participants increase their exercise. Therefore, there were no differences in depressive symptoms between the 2 study arms. Limitations of this study included a small sample size and lack of control for contact time in the usual care arm. Another study using an observational design examined the effect of exercise before and during the last trimester of pregnancy on depressive symptoms during the postpartum phase.51 The data obtained for the study was taken from the Pregnancy Risk Assessment Monitoring System, which is an annual assessment conducted by the Centers for Disease Control (n = 2169). Physical activity and mood were self-reported within the overall survey, both telephone and survey based. Results indicated that there was no correlation between being physically active before and/or during pregnancy and feelings of depression;
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however, there was a significant correlation between having little interest or pleasure and reporting physical activity both before pregnancy and during the last trimester of pregnancy. A strength of this study was the large sample size; however, a significant limitation was the small number of survey items assessing physical activity and depression. Finally, Abraham and colleagues52 examined the effect of exercise and eating behaviors during pregnancy on depressive symptoms following childbirth. Participants (n = 181) were women who had given birth during the week prior to the study. They completed a structured interview and a questionnaire that retrospectively assessed health behaviors during pregnancy. The EPDS was used to assess depressive symptoms. Participants who reported low-intensity exercise during early pregnancy to control weight and shape were less likely to report postpartum depression following birth than women not reporting exercise. Therefore, it appears that exercise during pregnancy may have a protective effect on postpartum depression. However, because of a lack of randomization, definitive causation cannot be inferred regarding the link between exercise and depression. Limitations There were several limitations of the pregnancy and postpartum studies included in this review. First, none of the 4 pregnancy studies reviewed were randomized trials (ie, 2 were observational and 2 were nonrandomized group designs). Another limitation is that a majority of the pregnancy studies used the POMS to assess mood. This is problematic, given that the POMS is a current measure of mood and does not assess specific depressive symptoms during the previous 2 weeks. There were significantly more postpartum studies examining exercise and depression relative to the pregnancy studies. Specifically, 6 of the 9 postpartum studies were randomized trials, 2 were observational, and 1 was a nonrandomized group design. One limitation of the postpartum studies is that
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many of the studies used the Edinburgh Depression Inventory to assess depression, which is a limitation, given that a structured interview is preferred for proper assessment. Summary and Conclusions In summary, research indicates that exercise might be beneficial for improving mood and anxiety during pregnancy and the postpartum phase. Regarding the pregnancy studies, 3 of the 4 studies did find a relationship between exercise and mood, and the 1 study not finding an effect had a very small sample size (n = 12). The findings did not appear to vary depending on the trimester of pregnancy. Of the 3 studies finding an effect, 1 study did not examine the effect of the trimester,41 another study only included participants in the second and third trimester,40 and a third study found an effect of exercise on mood in the first and second trimester but not in the third trimester.42 The type and duration of exercise also did not appear to alter the findings. Of the 2 studies examining specific types of exercise, 1 study found that a 90-minute aerobic exercise session improved mood.41 Another study found that both an aqua and gym class improved mood as measured by the POMS.40 This study also found that the aqua class exhibited lower scores on the depression subscale of the POMS (lower depression), indicating some preliminary evidence that the aqua class may have been more influential on mood than the gym class. More research is needed to further examine this finding. Not surprisingly, the studies including 20 or more participants found an effect of exercise on mood, and the study including only 12 participants did not find an effect. Taken together, it appears that there may be a relationship between exercise and mood during pregnancy; however, additional research using large randomized controlled designs are needed. Regarding the 9 postpartum studies, 5 found an effect of exercise on depression. There did not appear to be a pattern regarding sample size, randomization,

or type of measure affecting efficacy. Several of the studies included walking, whereas others included low-intensity exercise such as yoga and low-intensity stretching. The study including low-intensity stretching did not find an effect of exercise on depression.45 Other than this 1 study, type of exercise did not appear to have an impact on the effect of exercise on depression. The duration of exercise ranged from 30 to 60 minutes per session across the studies. The duration of exercise also did not appear to influence the results of the depression scores. Because there were only 9 studies examining the effect of exercise on depression during the postpartum phase, additional research is needed. Practical Implications Based on the preliminary evidence indicating that exercise may be important in the prevention and treatment of depression during pregnancy and postpartum and given that exercise is helpful for improving overall health, we suggest that practitioners advise their patients to exercise in cases in which exercise is not contraindicated. Practical implications are outlined in more detail below. Obstetricians, certified nurse midwives, nurse practitioners, primary care clinicians, and pediatricians are in a unique position to screen for depression during pregnancy and postpartum. A majority of women see their health care providers several times during pregnancy and should be routinely screened for depression during these visits. Additionally, postpartum depression can be screened at the 6-week appointment following childbirth and at the newborns well-child visits. The PHQ-9 is a short 9-item questionnaire that can be used to assess depression during pregnancy.53 Specific items include depressed mood, diminished pleasure, sleep disturbance, low energy, self-deprecation, appetite changes, psychomotor changes, difficulty concentrating, and suicidal thoughts. Either the PHQ-9 or the EPDS can be used to assess postpartum depression. The EPDS is a 10-item scale specifically designed to assess postpartum

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depression.54 Items assess enjoyment, selfblaming, anxiety, panic feelings, coping skills, happiness, crying, and suicidal thoughts. Patients who score positive for depression should be referred to a mental health professional for further treatment. The limitation of these instruments is that they rely on self-report, whereas a structured clinical interview would be preferred. However, a structured interview is frequently not possible, given its lengthy time commitment. Therefore, self-report measures can be used as a screening measure to determine if further evaluation is needed. Kroenke et al55 have found the PHQ-9 to be reliable and valid and it is the recommended screening tool to be used in primary care offices.56 Regarding the EPDS, it has good sensitivity (79%) and specificity (85%) when compared with a structured clinical interview.57 The American College of Obstetrics and Gynecologists recommend that pregnant and postpartum women routinely exercise, and research indicates that exercise might help with depression during pregnancy and the postpartum phase. Therefore, we recommend that health care providers advise their patients to exercise. Health care providers could provide exercise prescriptions to women and discuss the benefits of exercise in regard to mood. Additionally, parent classes, walking groups, and support groups could be provided. It should be noted that in some cases, exercise may be contraindicated. For example, exercise during pregnancy should be stopped if any of the following occur: (1) placenta previa after 26 weeks of gestation, (2) premature labor, (3) persistent second or third trimester bleeding, (4) ruptured membranes, or (5) preeclampsia/ pregnancy-induced hypertension.58 More information on the safety of exercise during pregnancy is available elsewhere.58 It is important to note that exercise alone may not prevent depression, and in these cases, additional psychological services and referrals may be necessary. Acknowledgment This project was supported in part through a grant from the National Institute of Mental Health (MH073820). AJLM

References
1. Dietz PM, Williams SB, Callaghan WM, Bachman DJ, Whitlock EP, Hornbrook MC. Clinically identified maternal depression before, during, and after pregnancies ending in live births. Am J Psychiatry. 2007;164:1515-1520. Gavin NI, Gaynes BN, Lohr KN, MeltzerBrody S, Gartlehner G, Swinson T. Perinatal depression: a review of prevalence and incidence. Obstet Gynecol. 2005;106:1071-1083. OHara MW, Swain AM. Rates and risk of postpartum depression-a meta-analysis. Int Rev Psychiatry. 2005;8:37-54. Wadwha PD, Sandman C, Poroto M, Dunkel-Schetter C, Garite T. The association between prenatal stress and infant birth weight and gestational age at birth: a prospective investigative investigation. Am J Obstet Gynecol. 1993;169:858-865. Lundy B, Jones N, Field T, et al. Prenatal depression effects on neonates. Infant Behav Dev. 1999;22:119-129. Bledsoe SE, Grote KN. Treating depression during pregnancy and the postpartum: a preliminary meta-analysis. Res Soc Work Pract. 2006;16:109-120. Dennis CL, Hodnett E. Psychosocial and psychological interventions for treating postpartum depression. Cochrane Database Syst Rev. 2007;(4):CD006116. Butler R, Carney S, Cipriani A, et al. Depressive disorders. Am Fam Physician. 2006;73:1999-2004. Furukawa T, McGuire H, Barbui C. Low dosage tricyclic antidepressants for depression. Cochrane Database Syst Rev. 2003;(3):CD003197. Cohen LS, Altshuler LL, Harlow BL, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA. 2006;295:499-508. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry. 2009;31:403-413. Nonacs R, Cohen LS. Assessment and treatment of depression during pregnancy: an update. Psychiatr Clin N Am. 2003;26:547-562. Jeffries WS, Bochner F. The effect of pregnancy on drug pharmacokinetics. Med J Aust. 1988;149:675-677. Krauer B. Pharmacotherapy during pregnancy: emphasis on pharmacokinetics. In: London MF, ed. Drug Therapy During Pregnancy. Butterworths; 1985:9-31. Robertson ES, Grace S, Wallington T, Stewart DE. Antenatal risk factors for 16.

2.

17.

3.

18.

4.

19.

5.

20.

6.

7.

21.

8.

22.

9.

23.

10.

24.

11.

25.

12.

26.

13.

27.

14.

28.

15.

postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry. 2004;26:289-295. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994. Robinson GE, Stewart DE. Postpartum disorders. In: Stotland NL, Stewart DE, eds. Psychological Aspects of Womens Health Care. Washington, DC: American Psychiatric Press; 2001:117-139. Horowitz JA, Bell M, Trybulski J, et al. Promoting responsiveness between mothers with depressive symptoms and their infants. J Nurs Scholarsh. 2001;33:323-329. Beeghly M, Olson KL, Weinberg MK, Pierre SC, Downey N, Tronick EZ. Prevalence, stability, and socio-demographic correlates of depressive symptoms in black mothers during the first 18 months postpartum. Matern Child Health J. 2007;7:157-168. Whiffen, VE, Gotlib IH. Comparison of postpartum and nonpostpartum depression: clinical presentation, psychiatric history, and psychosocial functioning. J Consult Clin Psychol. 1993;61:485-94. Mayberry LJ, Horowitz JA, Declercq E. Depression symptom prevalence and demographic risk factors among U.S. women during the first 2 years postpartum. J Obstet Gynecol Neonatal Nurs. 2007;36:542-549. Logsdon MC, Wisner KL, Pinto-Foltz MD. The impact of postpartum depression on mothering. J Obstet Gynecol Neonatal Nurs. 2006;35:652-658. Cooper PJ, Murray L. Course and recurrence of postnatal depression: evidence for the specificity of the diagnostic concept. Br J Psychiatry. 1995;166:191-195. Hipwell AE, Goossen FA, Melhuish EC, Kumar R. Severe maternal psychopathology and infant-mother attachment. Dev Psychopathol. 2000;12:157-175. Murray L, Fiori-Cowley A, Hooper R, Cooper P. The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome. Child Dev. 1996;67:2512-2526. Areias ME, Kumar R, Barros H, Figueiredo E. Correlates of postnatal depression in mothers and fathers. Br J Psychiatry. 1996;169:36-41. Goodman JH. Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. J Adv Nurs. 2004;45:26-35. Dennis CL, Chung-Lee L. Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review. Birth. 2006;33:323-331.
377

American Journal of Lifestyle Medicine

July Aug 2011

29. Gjerdingen D. The effectiveness of various postpartum depression treatments and the impact of antidepressant drugs on nursing infants. J Am Board Fam Pract. 2003;16:372-382. 30. Appleby L, Warner R, Whitton A, Faragher B. A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. BMJ. 1997;314:932-936. 31. Misri S, Reebye P, Corral M, Milis L. The use of paroxetine and cognitive-behavioral therapy in postpartum depression and anxiety: a randomized controlled trial. J Clin Psychiatry. 2004;65:1236-1241. 32. Buist A, Bilszta J, Barnett B, et al. Recognition and management of perinatal depression in general practice: a survey of GPs and postnatal women. Aust Fam Physician. 2005;34:787-790. 33. Whitton A, Warner R, Appleby L. The pathway to care in postnatal depression: womens attitudes to postnatal depression and its treatment. Br J Gen Pract. 1996;46:427-428. 34. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosom Med. 2007;69:587-596. 35. Dunn AL, Trivedi MH, Kampert JB, Clark CG, Chambliss HO. Exercise treatment for depression: efficacy and dose response. Am J Prev Med. 2005;28:1-8. 36. Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on older patients with major depression. Arch Intern Med. 1999;159:2349-2356. 37. Babyak M, Blumenthal JA, Herman S, et al. Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Psychosom Med. 2000;62:633-638. 38. Brosse AL, Sheets ES, Lett HS, Blumenthal JA. Exercise and the treatment of clinical depression in adults: recent findings and future directions. Sports Med. 2002;32:741-760.

39. Daley A, Jolly K, MacArthur C. The effectiveness of exercise in the management of post-natal depression: systematic review and meta-analysis. Fam Pract. 2009;26:154-162. 40. Polman R, Kaiseler M, Borkoles E. Effect of a single bout of exercise on the mood of pregnant women. J Sports Med Phys Fitness. 2006;47:103-111. 41. Koltyn KF. Mood changes in pregnant women following an exercise session and a prenatal information session. Womens Health Issues. 1994;4:191-195. 42. Da Costa D, Rippen N, Dritsa M, Ring A. Self-reported leisure-time physical activity during pregnancy and relationship to psychological well-being. J Psychosom Obstet Gynaecol. 2003;24:111-119. 43. Poudevigne MS, OConnor PJ. Physical activity and mood during pregnancy. Med Sci Sports Exerc. 2005;37:1374-1380. 44. Koltyn KF, Schultes SS. Psychological effects of an aerobic exercise session and a rest session following pregnancy. J Sports Med Phys Fitness. 1997;37: 287-291. 45. Ko YL, Yang CL, Chaing LC. Effects of postpartum exercise program on fatigue and depression during doing the month period. J Nurs Res. 2008;16:177-185. 46. Dritsa M, Da Costa D, Dupuis G, Lowensteyn I, Khalife S. Effects of a homebased exercise intervention on fatigue in postpartum depressed women: results of a randomized controlled trial. Ann Behav Med. 2008;35:179-187. 47. Heh SS, Huang LH, Ho SM, Fu YY, Wang LL. Effectiveness of an exercise support program in reducing the severity of postnatal depression in Taiwanese women. Birth. 2008;35:60-65. 48. Armstrong KJ, Edwards H. The effects of exercise and social support on mothers reporting depressive symptoms: a pilot randomized controlled trial. Int J Ment Health Nurs. 2003;12:130-138.

49. Armstrong K, Edwards H. The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women. Int J Nurs Pract. 2004;10:177-194. 50. Daley A, Winter H, Grimmett C, McGuinness M, McManus R, MacArthur C. Feasibility of an exercise intervention for women with postnatal depression: a pilot randomised controlled trial. Br J Gen Pract. 2008;58:178-183. 51. Ersek JL, Brunner Huber LR. Physical activity prior to and during pregnancy and risk of postpartum depressive symptoms. J Obstet Gynecol Neonatal Nurs. 2009;38:556-566. 52. Abraham S, Taylor A, Conti J. Postnatal depression, eating, exercise, and vomiting before and during pregnancy. Int J Eat Disord. 2001;29:482-487. 53. Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Ann. 2002;32: 509-521. 54. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786. 55. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Int Med. 2001;16:606-613. 56. Nease DE, Malouin JM. Depression screening: a practical strategy. J Fam Pract. 2003;52:118-126. 57. Cox JL, Chapman G, Murray D, Jones P. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in non-postnatal women. J Affect Disord. 1996;39:185-189. 58. Lewis BA, Avery M, Jennings E, Sherwood N, Martinson B, Crain AL. The effect of exercise during pregnancy on maternal outcomes: practical implications for practice. Am J Lifestyle Med. 2008;2:441-455.

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