The Role of Exercise in Treating Postpartum Depression: A Review of the Literature

Dose-Response Effects on LBP, Sleep, and Depression of Online Pre-Partum and Post-Partum Pilates-Based Programs

Purpose: Pilates-based programs can help pregnant women deal with the physical and psychological burden derived by major changes in their body. This study was designed to primarily test, in pregnant women, the dose-response and health effects of both pre-partum and post-partum, online Pilates-based program on weight control, low back pain (LBP) severity, sleep disturbances, mood and depression levels. Methods: A total of 136 pregnant women were screened for eligibility (low-risk pregnancy; aged 18-45 years; single pregnancy; 20-28-week gestational age, normal BMI). Participants completed an online Pilates-based program during pregnancy and after delivery, through an online platform guided by a Pilates, Yoga and Lagree certified instructor. Main outcomes (weight control, LBP disability, sleep quality, mood, and mental health) were assessed at baseline and at the completion of pre- and post-partum programs. Results: Regarding pre-partum, significant gains in weight were observed only in low- and intermediate-amount exercisers. Only high-amount exercisers did not display significant increase in LBP-related disability (+42.7%; p = .21) unlike low (+12.2%; p < .0001) and intermediate exercisers (+9.6%; p < .0001). Sleep disturbances increased significantly in low- (+24.3%; p = .005) but not in intermediate- (+4.6%; p = .50) and high-amount exercisers (-0.1%; p = .91). Regardless of the amount of exercise, depression scores improved in all groups. Following post-partum intervention (n = 40), only intermediate-amount exercisers showed significant reductions in sleep disturbances (-24.1%; p = .003) and depression (15.9%; p = .04). Conclusions: Approximately 270 min/week of an online Pilates-based program were needed to prevent LBP worsening, and sleep deterioration in pregnant women. A different pattern was outlined for those women resuming the Pilates-based intervention at post-partum, with 150 min/week emerging as the "dose" of exercise capable of inducing the largest improvements in LBP, sleep, and mood disturbances.

Understanding the challenges and impact of training on referral of postnatal women to a community physical activity programme by health professionals: A qualitative study using the COM-B model

OBJECTIVE

To understand the value of training for health professionals for improving their ability to effectively refer postnatal women to a targeted community physical activity programme. The study also sought to understand challenges to effective referral of postnatal women from deprived areas.

DESIGN, SETTING AND PARTICIPANTS

Semi-structured interviews were conducted in January-February 2020 with early years practitioners (n = 4), health visitors (n = 1) and community midwives (n = 2) who had participated in a training workshop implemented as part of a targeted community physical activity referral programme for postnatal women from deprived areas in the North East of England. Two follow up interviews were also conducted with one midwife and one early years practitioner during the Covid-19 pandemic. Data were analysed thematically and the Capability, Opportunity, Motivation, Behaviour (COM-B) model was employed to facilitate identification of the impact of training and the challenges in referral from the health professionals' perspective.

FINDINGS

The training increased capability to refer by improving knowledge and confidence of health professionals in being able to give appropriate guidance to postnatal women about physical activity without having to refer to other professionals. Health professionals reported adequate opportunities to engage with postnatal women, were motivated to refer and perceived this to be part of their role. The timing and method of message delivery were key contexts for perceived successful referral, particularly for midwives who wanted to ensure the messaging began in the antenatal period. Low staffing levels, limited interprofessional collaboration and finding strategies to engage women from deprived areas were key challenges to effective delivery of physical activity messages. These challenges were exacerbated during Covid-19, with increased mental health issues amongst postnatal women.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Training health professionals for physical activity messaging can be a useful way to increase capability, opportunity, and motivation to refer to physical activity interventions for postnatal women in deprived areas to potentially increase physical wellbeing and reduce postnatal depression. The COM-B is a relevant framework to underpin training. A clearly identified referral pathway and staffing issues need to be addressed to improve referrals by health professionals.

Associated factors of depression in pregnant women in Korea based on the 2019 Korean Community Health Survey: a cross-sectional study

Purpose

Various individual and social factors influence depression in pregnant women. The purpose of this study was to identify the influence of socioeconomic status, health behaviors, and health status on depression of pregnant women in Korea.

Methods

This study analyzed data from the 2019 Korean Community Health Survey conducted from August to October 2019. A structural questionnaire with Patient Health Quetsionnaire-9 (PHQ-9), health behavior, health status, and psychological characteristics was used. The data of 1,096 pregnant women between the ages of 19 and 55 years were analyzed using descriptive statistics, independent-test and chi-square tests, and multiple regression.

Results

The mean score of prenatal depression as measured by the PHQ-9 during pregnancy was 2.35 points out of 0 to 27 points. Low income (B=0.69, p<.001), low-education level (B=0.70, p<.001), skipping breakfast (B=0.34, p=.001), less than 8 hours of sleeping (B=0.26, p=.009), binge drinking during pregnancy (B=0.46, p=.001), and stress (B=1.89, p<.001) were significantly associated with increased depression scores. In contrast, depression scores significantly decreased as subjective health status (B=–0.59, p<.001) and subjective oral health status (B=–.17, p=.003) increased.

Conclusion

Findings support the need for healthcare policies and clinical screening to alleviate prenatal depression, especially for pregnant women with low socioeconomic status, poor health behavior, poor health status, and high stress.

Perceived Barriers and Motivators for Physical Activity in Women With Perinatal Depression

BACKGROUND

Physical activity (PA) can help reduce depression symptom severity in women with perinatal depression. However, PA is low, and barriers and motivators for PA among women with perinatal depression are not well understood.

METHODS

An ethnically diverse sample of women with perinatal depression was identified using a universal perinatal depression screening program. The authors conducted 8 focus groups (4 in pregnant women [n = 15] and 4 in postpartum women [n = 20]). Depression symptoms were measured using the Patient Health Questionnaire-8 at recruitment. Focus groups were analyzed using an inductive approach.

RESULTS

Pregnant participants were 27 weeks gestation, and postpartum participants were 11.5 months postpartum, on average. Depression symptoms were moderately severe (mean Patient Health Questionnaire-8 score: 16). Women identified practical barriers and motivators for PA common to perinatal women (physical health, parental responsibilities, PA tracking tools, and environmental factors) and described emotional and social factors influencing PA. Motivators included using PA to improve mood, relieve stress, boost self-image, and spend time with others. Bad mood, fear of social judgment, and feeling discouraged made it difficult to be active.

CONCLUSION

PA interventions in women with perinatal depression should include components addressing emotional and social barriers to PA in addition to addressing additional common practical barriers to PA.

Mums on the Move: A pilot randomised controlled trial of a home-based physical activity intervention for mothers at risk of postnatal depression

BACKGROUND

Postnatal women are commonly physically inactive, and, when coupled with depressive symptoms, barriers to physical activity can be heightened. This study aimed to 1) examine the feasibility and acceptability of a multi-component home-based physical activity intervention delivered to mothers at risk of postnatal depression, and 2) examine changes in health behaviours (physical activity, sedentary behaviour, sleep, diet) and indicators of mental health.

METHODS

Sixty-two mothers (3 - 9 months postpartum) who at baseline were insufficiently active and experiencing heightened depressive symptoms were recruited into a 12-week randomised controlled trial in 2018. Participants were randomised into either a) Intervention group (receiving a theoretically underpinned multi-component program including free exercise equipment at home, access to smartphone web-app, and an online forum); or b) Control group (usual routine). Primary outcomes were program feasibility and acceptability. Secondary outcomes included self-reported and accelerometer-assessed physical activity and sedentary behavior, sleep, diet, determinants of physical activity, and mental health (depressive and anxiety symptoms), measured at baseline and follow-up (12-weeks), with self-reported physical activity, sedentary behaviour and depressive symptoms also measured at weeks 4 and 8. Qualitative data was analysed following inductive content analysis, and quantitative data using linear mixed models.

RESULTS

Exercise equipment use in the home was shown to be a feasible strategy to re-engage postnatal women in physical activity. Other components of the program (e.g. web-app, online forum) had low compliance. The program had high acceptability, predominately due to its accessibility, flexibility and ability to overcome key barriers to physical activity. The program resulted in improvements in short-term self-reported physical activity (increased 162min/week at 4 weeks, 95% CI: 37.7, 286.2), behavioural skills (B=0.4, 95% CI: 0.0, 0.8) and perceived barriers to physical activity. However, accelerometer measured physical activity decreased in the intervention group, compared to control group at week 12 (B=-1.3, 95% CI:-2.5, -0.1). There were no changes in other outcomes.

CONCLUSIONS

A home-based physical activity program involving free exercise equipment is acceptable and feasible amongst women experiencing heightened postnatal depressive symptoms. Such programs may be effective in increasing engagement in physical activity, yet additional strategies may be needed to enhance maintenance of physical activity and improvements in mental health.

Reduction in physical activity significantly increases depression and anxiety in the perinatal period: a longitudinal study based on a self-report digital assessment tool

PURPOSE

Physical activity can reduce pregnancy-related complications and contributes substantially to improving maternal mental health. A reduction in activity encompassing exercise and daily household tasks throughout the course of pregnancy increases the risk of depression and anxiety. The following research examines the longitudinal interaction between exercise, general physical activity, and mental health outcomes in pregnant women.

METHODS

This prospective longitudinal study was conducted at the maternity departments of two major university hospitals in Germany. Self-reported data of 597 women were digitally assessed every 4 weeks from the second trimester until birth as well as 3 and 6 months postnatally. Depressive and anxiety symptoms were assessed using the EPDS, PRAQ, and STAI and physical activity levels were measured using the PPAQ questionnaire. Cross-sectional and longitudinal analyses using Pearson's correlation coefficient and multiple regression models were conducted.

RESULTS

We found a significant reduction in general physical activity in the period from the 20th to 32nd gestational week. Women who reported a greater decline during pregnancy showed significantly higher depression and anxiety scores. In stratified analyses, only baseline mental health scores proved to be variables with stronger impact on postnatal depression and anxiety outcomes.

CONCLUSION

General physical activity and maternal mental health significantly influence each other during and after pregnancy. Both physical activity and the prevention of perinatal mental disorders should be systematically encouraged during perinatal care to prevent adverse maternal and fetal birth outcomes.

Association of prenatal psychological distress and postpartum depression with varying physical activity intensity: Japan Environment and Children's Study (JECS)

Evidence is mixed on the associations between physical activity during pregnancy and perinatal depression, and it is limited for different physical activity intensities. Data for 92,743 pregnant women from the Japan Environment and Children’s Study were analyzed in this study. Psychological distress during pregnancy was assessed as moderate or severe using the Kessler Psychological Distress Scale (K6 5–12 and ≥13, respectively). Postpartum depression was assessed using the Edinburgh Postpartum Depression Scale (EPDS; cut-off score 9). Women with only light physical activity had significantly lower odds of psychological distress during pregnancy than those with no physical activity (K6 5–12: adjusted odds ratio [AOR] 0.86, 95% confidence interval [95%CI] 0.82, 0.90; K6 ≥ 13: AOR 0.64, 95%CI 0.58, 0.72). Women with a combination of light, moderate and vigorous physical activity had significantly higher odds of psychological distress during pregnancy (K6 5–12: AOR 1.32, 95%CI 1.18, 1.48; K6 ≥ 13: AOR 1.45, 95%CI 1.16, 1.81) and depression after childbirth (EPDS ≥ 9: AOR 1.42, 95%CI 1.24, 1.61). Physical activity intensity should be considered when assessing psychological distress risk during pregnancy and depression risk after delivery. Future research should evaluate specific physical activity programs with optimal intensity for pregnant women to prevent and treat their psychological distress and depression.

The maternal reward system in postpartum depression

The experience of motherhood is most often emotionally positive and rewarding, but for many new mothers suffering from postpartum depression (PPD), this is not the case. Preclinical and clinical research has sought to uncover brain changes underlying PPD in order to gain a better understanding of how this disorder develops. This review focuses on the mesolimbic dopamine system, particularly the ventral tegmental area-nucleus accumbens pathway which has been implicated in the regulation of critical functions disrupted in PPD including mood, motivation, and mothering. Specifically, we discuss normative changes in the mesolimbic system during motherhood in both rodents and humans and how these are impacted in PPD. We also consider modulation of mesolimbic dopamine by the hypothalamic neuropeptide oxytocin and how oxytocin-dopamine interactions regulate mood and mothering during the postpartum period. In addition to providing an overview of reward mechanisms in PPD, our goal is to highlight open questions which warrant further research.

Psychosocial and demographic predictors of postpartum physical activity

Physical activity promotes better health outcomes across the lifespan, and provides physical and mental health benefits for women who have recently given birth. However, research has not adequately characterized physical activity levels or risk factors for inadequate physical activity during the postpartum period. The objective of the present study was to describe levels and correlates of physical activity at 6 months postpartum in mothers of diverse race/ethnicity (55% African American, 23% White, 22% Hispanic/Latina), with the majority living in or near poverty. We analyzed data collected by the five-site Community Child Health Network study. Women (n = 1581) were recruited shortly after the birth of a child. Multinomial logistic regression models tested associations of demographic factors and self-reported stress in several life domains with total physical activity levels at 6-9 months postpartum, including activities done at work, at home, for transportation, and leisure. Thirty-five percent of participants in this sample reported low levels of physical activity. African American race, Latina ethnicity, and living in a rural area were associated with low levels of physical activity, whereas working outside the home was associated with high physical activity. Contrary to hypotheses, chronic stress was not associated with physical activity with the exception of financial stress, which predicted greater likelihood of being highly physically active. These findings suggest that optimal postpartum care should integrate physical activity promotion, and that African American, Latina, and rural-dwelling women may benefit most from efforts to promote activity following birth.

Physical activity in pregnancy and postpartum depressive symptoms in a multiethnic cohort

INTRODUCTION

There is strong evidence that postpartum depression is associated with adverse health effects in the mother and infant. Few studies have explored associations between physical activity in pregnancy and postpartum depression. We aimed to investigate whether physical activity during pregnancy was inversely associated with postpartum depressive symptoms, PPDS in a multiethnic sample.

METHOD

Population-based, prospective cohort of 643 pregnant women (58% ethnic minorities) attending primary antenatal care from early pregnancy to postpartum in Oslo between 2008 and 2010. Data on demographics and health outcomes were collected during standardized interviews. PPDS was defined by a sum score ≥10 from the Edinburgh Postnatal Depression Scale (EPDS), 3 months after birth. Physical activity was recorded with Sense Wear™ Pro3 Armband (SWA) in gestational week 28 and defined as moderate-to-vigorous intensity physical activity (MVPA) accumulated in bouts ≥10 min.

RESULTS

Women who accumulated ≥150 MVPA minutes/week had significantly lower risk (OR = 0.2, 95% CI: 0.06-0.90), for PPDS compared to those who did not accumulate any minutes/week of MVPA, adjusted for ethnic minority background, depressive symptoms in the index pregnancy and self-reported pelvic girdle syndrome. The results for MVPA persisted in the sub-sample of ethnic minority women.

LIMITATIONS

Numbers of cases with PPDS were limited. The SWA does not measure water activities. Due to missing data for SWA we used multiple imputations.

CONCLUSION

Women meeting the physical activity recommendation (>150 MVPA min/week) during pregnancy have a lower risk of PPDS compared to women who are not active during pregnancy.

Physical exercise programme during pregnancy decreases perinatal depression risk: a randomised controlled trial

Introduction

The incidence of depression is high during the perinatal period. This mood disorder can have a significant impact on the mother, the child and the family.

Objective

To examine the effect of an exercise programme during pregnancy on the risk of perinatal depression.

Methods

Healthy women who were <16 weeks pregnant were randomly assigned to two different groups. Women in the intervention group participated in a 60 min exercise programme throughout pregnancy, 3 days per week, which was conducted from October 2014 to December 2016. The Center for Epidemiological Studies-Depression Scale was used to measure the risk of depression at the beginning of the study (12–16 weeks), at gestational week 38 and at 6 weeks postpartum.

Results

One hundred and twenty-four pregnant women were allocated to either the intervention (IG=70) or the control (CG=54) group. No differences were found in the percentage of depressed women at baseline (20% vs 18.5%) (χ2=0.043; p=0.836). A smaller percentage of depressed women were identified in the IG compared with the CG at 38 gestational weeks (18.6% vs 35.6%) (χ2=4.190; p=0.041) and at 6 weeks postpartum (14.5% vs 29.8%) (χ2=3.985; p=0.046) using the per-protocol analysis. No significant differences were found using the intention-to-treat analyses, except in the multiple imputation analysis at week 38 (18.6% vs 34.4%) (χ2=4.085; p=0.049).

Conclusion

An exercise programme performed during pregnancy may reduce the prevalence of depression in late pregnancy and postpartum.

Trial registration number

NCT02420288; Results.

Effects of Implementing the Alexander Technique on Enjoying the Sense of Motherhood in the Postpartum Period

BACKGROUND

The broad concept of maternal well-being includes psychological concepts, social aspects, and aspects of becoming a mother. The present study aimed to investigate the effects of implementing the Alexander technique on enjoying the sense of motherhood.

MATERIALS AND METHODS

This study was a clinical trial conducted in two phases. In the first phase, using the exploratory and confirmatory factor analysis, 226 mothers were asked to undergo a scale test of enjoying the sense of motherhood after childbirth. In the second phase, 88 pregnant women were divided into two experimental groups. The data collection tool was a researcher-made questionnaire about enjoying the sense of motherhood. Independent samples t-test, Mann-Whitney test, Chi-square test, Fisher's exact test, analysis of variance test, Box test, and Levine test were used to analyze the data.

RESULTS

Results of this study showed that the mean scores of the constructs of enjoying pregnancy (P > 0.001), motherhood, and child care satisfaction (P > 0.001) in the experimental group were significantly higher than the control group. Moreover, the construct of trusting their own abilities to cope with maternal duties (P > 0.01) did not show significant differences between the two groups.

CONCLUSIONS

The findings indicated that the Alexander technique can promote mothers' psychological well-being and their pleasure of becoming a mother and the related constructs. Results also revealed that using this technique, educating and recommending pregnant women to use this technique will be beneficial.

Effectiveness of aerobic gymnastic exercise on stress, fatigue, and sleep quality during postpartum: A pilot randomized controlled trial

BACKGROUND

Gymnastics is a preferable safe exercise for postnatal women performing regularly.

OBJECTIVE

The aim of this pilot randomized controlled trial was to determine whether the aerobic gymnastic exercise improves stress, fatigue, sleep quality and depression in postpartum women.

DESIGN

Single-blinded, randomized controlled trial held from December 2014 until September 2015.

SETTING

Postnatal clinic of a medical center in southern Taiwan.

PARTICIPANTS

140 eligible postnatal women were systematically assigned, with a random start to experimental (n=70) or a control (n=70) group.

INTERVENTIONS

Engage in aerobic gymnastic exercise at least three times (15min per section) a week for three months using compact disc in the home.

OUTCOME MEASURES

Perceived Stress Scale, Postpartum Fatigue Scale, Postpartum Sleep Quality Scale, and Edinburgh Postnatal Depression Scale.

RESULTS

In a two-way ANOVA with repeated measures, the aerobic gymnastic exercise group showed significant decrease in fatigue after practicing exercise 4 weeks and the positive effects extended to the 12-week posttests. Paired t-tests revealed that aerobic gymnastic exercise participants had improved significantly in perceived stress and fatigue after 4 weeks gymnastic exercise; these positive effects extended to the 12-week posttests. In addition, the changes in physical symptoms-related sleep inefficiency after 12 weeks gymnastic exercise were significantly decreased in the experimental group compared with the control group.

RELEVANCE TO CLINICAL PRACTICE

The findings can be used to encourage postnatal women to perform moderate-intensity gymnastic exercise in their daily life to reduce their stress, fatigue and improve sleep quality.

Effects of exercise-based interventions on postpartum depression: A meta-analysis of randomized controlled trials

BACKGROUND

There is inconsistent evidence about the effect of physical activity on the prevention and treatment of depression during the postnatal period. The aim of this meta-analysis was to determine the effect of physical activity interventions during pregnancy and the postpartum period for controlling postpartum depressive symptoms.

METHODS

We systematically searched Cochrane Library Plus, Science Direct, EMBASE, CINAHL, PubMed, Web of Science, and Scopus, from January 1990 to May 2016, for randomized or nonrandomized controlled trials addressing the effect of physical activity on postpartum depression. The inverse variance-weighted method was used to compute pooled estimates of effect size and respective 95% confidence intervals (95% CI) for physical activity intervention on postpartum depression. Subgroup analyses were performed comparing women with and without postpartum depressive symptoms according to specific scales measuring this construct. Meta-regression and sensitivity analysis were computed to evaluate heterogeneity.

RESULTS

Twelve studies were included in the meta-analysis. Effect size for the relationship between physical activity interventions during pregnancy and the postpartum period on postpartum depressive symptoms was 0.41 (95% CI 0.28-0.54). Heterogeneity was I²  = 33.1% (P = .117). When subgroup analyses were done, pooled effect sizes were 0.67 (95% CI 0.44-0.90) for mothers who met postpartum depressive symptoms criteria at baseline based on specific scales, and 0.29 (95% CI 0.14-0.45) for mothers who did not meet those depressive symptoms criteria at baseline.

CONCLUSION

Physical exercise during pregnancy and the postpartum period is a safe strategy to achieve better psychological well-being and to reduce postpartum depressive symptoms.

Exercise Behaviors and Health Conditions of Runners After Childbirth

Background:

With a recent increase in running popularity, more women choose to run during and after pregnancy. Little research has examined exercise behaviors and postpartum health conditions of runners.

Hypothesis:

Antenatal and postpartum exercise is beneficial in reducing certain postpartum health conditions.

Study Design:

Cross-sectional study.

Level of Evidence:

Level 5.

Methods:

A self-administered, online survey was developed that consisted of questions regarding antenatal and postpartum exercise behaviors, maternal history, and postpartum health conditions. The survey was completed by 507 postpartum women who were running a minimum of once per week.

Results:

Seventy-two percent of participants ran regularly during pregnancy, with 38% reporting running in the third trimester. Women with musculoskeletal pain during pregnancy were more likely to experience pain on return to running postpartum (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.64-5.88). A birth spacing of <2 years or a vaginal-assisted delivery increased the odds of postpartum stress urinary incontinence (OR, 1.71; 95% CI, 1.00-2.91 and OR, 2.08; 95% CI, 1.24-3.47, respectively), while Caesarean section delivery decreased the odds (OR, 0.58; 95% CI, 0.35-0.96). Multiparous women and those who reported a Caesarean section delivery were more likely to report abdominal separation (OR, 2.11; 95% CI, 1.08-4.26 and OR, 2.20; 95% CI, 1.05-4.70, respectively). Antenatal weight training decreased the odds of postpartum pain (OR, 0.52; 95% CI, 0.28-0.94), stress urinary incontinence (OR, 0.46; 95% CI, 0.21-0.98), and abdominal separation (OR, 0.51; 95% CI, 0.26-0.96).

Conclusion:

Musculoskeletal pain, stress urinary incontinence, and abdominal separation are prevalent conditions among postpartum runners and are more likely to occur with specific maternal history characteristics. Antenatal weight training may reduce the odds of each of these conditions.

Clinical Relevance:

Strengthening exercises during pregnancy may prevent weakening and dysfunction of the abdominal and pelvic floor muscles, decreasing the odds of pain, stress urinary incontinence, and abdominal separation after pregnancy.

Oxytocin, Postnatal Depression, and Parenting: A Systematic Review

OBJECTIVE

To carry out a systematic review exploring the interconnections between oxytocin, postnatal depression (PND), and parenting. Questions include: (1) How does PND affect parenting? (2) How does oxytocin affect parenting? (3) How does oxytocin affect PND?

METHODOLOGY

To review English articles in major medical databases.

RESULTS

Compared to nondepressed controls, mothers with PND interact with their infants less sensitively, report feeling less competent, and less often choose recommended practical-parenting strategies. Psychological interventions for mothers with PND generally have positive effects on mother-infant interactions. The administration of oxytocin in community samples tends to improve parental behaviors. Findings exploring the association between oxytocin and PND were inconsistent, with some evidence that oxytocin has a negative impact on mood.

CONCLUSIONS

Oxytocin is potentially useful in improving parental behaviors of mothers with PND, but more research is needed to establish its safety because of the uncertain impact of OT on maternal mood.

Postpartum depression: Etiology, treatment and consequences for maternal care

This article is part of a Special Issue "Parental Care". Pregnancy and postpartum are associated with dramatic alterations in steroid and peptide hormones which alter the mothers' hypothalamic pituitary adrenal (HPA) and hypothalamic pituitary gonadal (HPG) axes. Dysregulations in these endocrine axes are related to mood disorders and as such it should not come as a major surprise that pregnancy and the postpartum period can have profound effects on maternal mood. Indeed, pregnancy and postpartum are associated with an increased risk for developing depressive symptoms in women. Postpartum depression affects approximately 10-15% of women and impairs mother-infant interactions that in turn are important for child development. Maternal attachment, sensitivity and parenting style are essential for a healthy maturation of an infant's social, cognitive and behavioral skills and depressed mothers often display less attachment, sensitivity and more harsh or disrupted parenting behaviors, which may contribute to reports of adverse child outcomes in children of depressed mothers. Here we review, in honor of the "father of motherhood", Jay Rosenblatt, the literature on postnatal depression in the mother and its effect on mother-infant interactions. We will cover clinical and pre-clinical findings highlighting putative neurobiological mechanisms underlying postpartum depression and how they relate to maternal behaviors and infant outcome. We also review animal models that investigate the neurobiology of maternal mood and disrupted maternal care. In particular, we discuss the implications of endogenous and exogenous manipulations of glucocorticoids on maternal care and mood. Lastly we discuss interventions during gestation and postpartum that may improve maternal symptoms and behavior and thus may alter developmental outcome of the offspring.

A pragmatic randomized controlled trial to evaluate the effectiveness of a facilitated exercise intervention as a treatment for postnatal depression: the PAM-PeRS trial

BACKGROUND

Postnatal depression affects about 10-15% of women in the year after giving birth. Many women and healthcare professionals would like an effective and accessible non-pharmacological treatment for postnatal depression.

METHOD

Women who fulfilled the International Classification of Diseases (ICD)-10 criteria for major depression in the first 6 months postnatally were randomized to receive usual care plus a facilitated exercise intervention or usual care only. The intervention involved two face-to-face consultations and two telephone support calls with a physical activity facilitator over 6 months to support participants to engage in regular exercise. The primary outcome was symptoms of depression using the Edinburgh Postnatal Depression Scale (EPDS) at 6 months post-randomization. Secondary outcomes included EPDS score as a binary variable (recovered and improved) at 6 and 12 months post-randomization.

RESULTS

A total of 146 women were potentially eligible and 94 were randomized. Of these, 34% reported thoughts of self-harming at baseline. After adjusting for baseline EPDS, analyses revealed a -2.04 mean difference in EPDS score, favouring the exercise group [95% confidence interval (CI) -4.11 to 0.03, p = 0.05]. When also adjusting for pre-specified demographic variables the effect was larger and statistically significant (mean difference = -2.26, 95% CI -4.36 to -0.16, p = 0.03). Based on EPDS score a larger proportion of the intervention group was recovered (46.5% v. 23.8%, p = 0.03) compared with usual care at 6 months follow-up.

CONCLUSIONS

This trial shows that an exercise intervention that involved encouragement to exercise and to seek out social support to exercise may be an effective treatment for women with postnatal depression, including those with thoughts of self-harming.

A systematic review of the relationship between postpartum sleep disturbance and postpartum depression

OBJECTIVE

To examine the relationship between postpartum sleep disturbance and postpartum depression and describe the characteristics and demographics of the samples.

DATA SOURCES

Electronic databases Medline, PubMed, Cochrane, EPOC, CINAHL, ProQuest, and Psych INFO. In addition, hand searches of bibliographies supplemented the electronic search.

STUDY SELECTION

English language primary studies on the relationship between postpartum sleep disturbance and postpartum depression were included. Thirteen observational studies met the inclusion criteria.

DATA EXTRACTION

Data that specified the relationship between sleep disturbance and postpartum depression were extracted from the studies. The data were organized per author, year, participants, setting, country, demographics, design, sample size, outcomes, evidence, and effect size.

DATA SYNTHESIS

The effect size indicating the relationship between sleep disturbance and postpartum depression across the studies ranged between 0.4 and 1.7. There was evidence of a strong relationship between sleep disturbance and postpartum depression; however, the participants in the 13 studies were predominantly educated, middle class, older than age 30 years, and White. Likewise, the definition and measurement of postpartum sleep varied across the studies, which increased the possibility of bias.

CONCLUSIONS

Further research within the postpartum period involving underserved, younger women and samples with more diversity in race and ethnicity are needed.

The relationship between postnatal depression, sociodemographic factors, levels of partner support, and levels of physical activity

Background: postnatal depression (PND) is defined as a psychological mood disorder that occurs in a mother within 6 weeks of her giving birth. It refers to an episode that causes mood disturbance and it could begin in, or extend into, the postpartum period. It is thought to have a high impact upon the mother's health as well as the family's functioning and the child's development. Socio-demographic, psych-social, and physical activity factors may all contribute to postpartum mood and ability to cope with responsibilities. The primary aim of this study was to determine which of these factors predicted PND in postpartum women. A secondary aim was to identify the socio-demographic and psycho-social predictors of physical activity in postpartum women.

Methods: The study used a cross-sectional correlational design. A sample of 150 postpartum women was sent a package of six standardized questionnaires.

Results: There was no association between physical activity and PND; however, older mothers, mothers of younger children, mothers who are less reluctant to ask for help, and mothers who are more satisfied with the help they get experience lower levels of PND. Mothers of older babies, mothers with more children, and less educated mothers are more likely to engage in caregiving activities, whereas mothers with fewer children and higher levels of partner support are more likely to engage in occupational activities. None of the socio-demographic factors or any of the parenting factors predicted levels of sporting activity.

Psychological distress, depression, anxiety, stress, and exercise in Australian and New Zealand mothers: A cross-sectional survey

Postnatal psychological well-being is a complex issue characterized by major changes in physical, social, and emotional health. In response to addressing limitations of previous research this study aimed to: (i) quantify psychological distress, depression, anxiety, and stress in a large sample of Australian and New Zealand mothers and to compare to Australian norm data; and (ii) identify any significant differences in psychological distress, depression, anxiety, and stress of the mothers when grouped according to their self-reported exercise incidence. Self-reported short-form version Depression Anxiety Stress Scale data were collected from 3601 Australia and New Zealand mothers with at least one child under the age of 5 years. Results demonstrated that this sample of mothers had significantly poorer psychological well-being than the general Australian population. Furthermore, with the exception of anxiety, psychological well-being of mothers who reported exercising three to four times per week was significantly and meaningfully more positive compared to those mothers that reported not to exercise.

Physical activity, sedentary behavior, and postnatal depressive symptoms: a review

CONTEXT

Postnatal depression is highly prevalent in mothers. Although physical activity has been found to reduce the risk of depression in the general population, little is known regarding its link with postnatal depression. This review examined original research investigating the relationship between physical activity and sedentary behavior dose (frequency, intensity, and duration) and domain, and postnatal depressive symptoms.

EVIDENCE ACQUISITION

A systematic search for original research investigating the relationship between physical activity and sedentary behavior dose and domain, and postnatal depressive symptoms, was performed using several electronic databases in early 2012. A total of ten observational and seven intervention studies were included.

EVIDENCE SYNTHESIS

Most studies (one cross-sectional, two longitudinal, and six intervention studies) found an inverse association between postpartum leisure-time physical activity (LTPA) and postnatal depressive symptoms. One longitudinal study found that occupational physical activity was positively associated with postnatal depressive symptoms. There was inconclusive evidence to suggest an optimal dose of postpartum physical activity for reducing postnatal depressive symptoms. Two longitudinal studies found an inverse association between antenatal LTPA and presence of postnatal depressive symptoms. One of two studies that investigated sedentary behavior found a positive cross-sectional association between sedentary behavior and presence of postnatal depressive symptoms.

CONCLUSIONS

Although studies are limited, on balance, LTPA prior to, during, and after pregnancy may be important for reducing the risk of postnatal depression. Further research is required to determine the optimal dose and domain of physical activity for reducing postnatal depressive symptoms as well as to examine the link between sedentary behavior and postnatal depressive symptoms.

Interventions (other than pharmacological, psychosocial or psychological) for treating antenatal depression

BACKGROUND

A meta-analysis of 21 studies suggests the mean prevalence rate for depression across the antenatal period is 10.7%, ranging from 7.4% in the first trimester to a high of 12.8% in the second trimester. Due to maternal treatment preferences and potential concerns about fetal and infant health outcomes, diverse non-pharmacological treatment options are needed.

OBJECTIVES

To assess the effect of interventions other than pharmacological, psychosocial, or psychological interventions compared with usual antepartum care in the treatment of antenatal depression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2013), scanned secondary references and contacted experts in the field to identify other published or unpublished trials.

SELECTION CRITERIA

All published and unpublished randomised controlled trials of acceptable quality evaluating non-pharmacological/psychosocial/psychological interventions to treat antenatal depression.

DATA COLLECTION AND ANALYSIS

Both review authors participated in the evaluation of methodological quality and data extraction. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

MAIN RESULTS

Six trials were included involving 402 women from the United States, Switzerland, and Taiwan. For most comparisons a single trial contributed data and there were few statistically significant differences between control and intervention groups.In a trial with 38 women maternal massage compared with non-specific acupuncture (control group) did not significantly decrease the number of women with clinical depression or depressive symptomatology immediately post-treatment (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.25 to 2.53; mean difference (MD) -2.30, 95% CI -6.51 to 1.91 respectively). In another trial with 88 women there was no difference in treatment response or depression remission rates in women receiving maternal massage compared with those receiving non-specific acupuncture (RR 1.33, 95% CI 0.82 to 2.18; RR 1.14, 95% CI 0.59 to 2.19 respectively).In a trial with 35 women acupuncture specifically treating symptoms of depression, compared with non-specific acupuncture, did not significantly decrease the number of women with clinical depression or depressive symptomatology immediately post-treatment (RR 0.47, 95% CI 0.11 to 2.13; MD -3.00, 95% CI -8.10 to 2.10). However, women who received depression-specific acupuncture were more likely to respond to treatment compared with those receiving non-specific acupuncture (RR 1.68, 95% CI 1.06 to 2.66).In a trial with 149 women, maternal massage by a woman's significant other, compared with standard care, significantly decreased the number of women with depressive symptomatology immediately post-treatment (MD -6.70, 95% CI -9.77 to -3.63). Further, women receiving bright light therapy had a significantly greater change in their mean depression scores over the five weeks of treatment than those receiving a dim light placebo (one trial, n = 27; MD -4.80, 95% CI -8.39 to -1.21). However, they were not more likely to have a treatment response or experience a higher remission rate (RR 1.79, 95% CI 0.90 to 3.56; RR 1.89, 95% CI 0.81 to 4.42).Lastly, two trials examined the treatment effect of omega-3 oils. Women receiving omega-3 had a significantly lower mean depression score following eight weeks of treatment than those receiving a placebo (one trial, n = 33; MD -4.70, 95% CI -7.82 to -1.58). Conversely, in a smaller trial (21 women) there was no significant difference in the change in mean depression scores for women receiving omega-3 and those receiving a placebo (MD 0.36, 95% CI -0.17 to 0.89), and women who received omega-3 were no more likely to respond to treatment (RR 2.26, 95% CI 0.78 to 6.49) or have higher remission rates (RR 2.12, 95% CI 0.51 to 8.84). Women in the placebo group were just as likely to report a side effect as those in the omega-3 group (RR 1.12, 95% CI 0.56 to 2.27).

AUTHORS' CONCLUSIONS

The evidence is inconclusive to allow us to make any recommendations for depression-specific acupuncture, maternal massage, bright light therapy, and omega-3 fatty acids for the treatment of antenatal depression. The included trials were too small with non-generalisable samples, to make any recommendations.

The projected effect of increasing physical activity on reducing the prevalence of common mental disorders among Canadian men and women: a national population-based community study

OBJECTIVE

Little quantitative research has been conducted on the effect of physical activity (PA) modification on the prevalence of mental disorders in a nationally representative sample. We aimed to provide quantitative evidence regarding the potential effectiveness of PA in the management of mental disorders.

METHODS

We used data from the national Canadian Community Health Survey of Mental Health and Well-being (CCHS 1.2) designed to represent the approximately the 25 million national community population aged 15 years and over in 2002.

RESULTS

Around 1 in 10 Canadians reported a 12-month mental disorder. Women reported more mood and anxiety disorders, men more substance dependence. Almost half of Canadians were physically inactive. After adjusting for covariates, physical inactivity was a significant risk factor for common mental disorders, except manic episode. Approximately 780,000 cases nationally are attributable to physical inactivity. A 10% reduction in the rate of physical inactivity would reduce common mental disorders by 167,000 cases, a 25% reduction would result in 389,000 fewer cases. PA was more beneficial for men.

CONCLUSIONS

Clinicians and public health campaigns targeting individual patients and general populations can improve patients' symptoms and prevent a significant proportion of future mental disorders by increasing the amount of PA.

Design and Rationale for a Randomized Controlled Trial Testing the Efficacy of Aerobic Exercise for Patients with Obsessive-Compulsive Disorder

BACKGROUND: Over the last two decades very few advances have been made in the development of new treatments for obsessive-compulsive disorder (OCD). While patients with OCD improve with available treatments (pharmacotherapy and/or cognitive-behavioral therapy), moderate levels of OCD symptoms often persist even with adequate doses and durations of these treatments. Building on the growing body of evidence for the efficacy of exercise in the treatment of other psychiatric disorders, interventions to increase aerobic exercise in patients with OCD represent a potentially useful yet relatively unexplored strategy in OCD. METHODS/DESIGN: One hundred and two (102) patients with clinically significant OCD symptoms despite current engagement in recommended treatments (pharmacotherapy and/or CBT) will be randomly assigned to receive either a 12-week moderate intensity aerobic exercise (AE) intervention or a health education control (HEC) intervention. Follow-up interviews will be conducted at the end of treatment and at 3-, 6- and 12-months post-intervention. They will assess OCD severity, nonspecific anxiety, depression, quality of life, cardiorespiratory fitness and cognition (executive function). DISCUSSION: If efficacy is established, patients with OCD who have clinically significant residual symptoms despite current pharmacotherapy or CBT would gain a valuable and practical treatment augmentation option.

The effectiveness of exercise as a treatment for postnatal depression: study protocol

BACKGROUND

Postnatal depression can have a substantial impact on the woman, the child and family as a whole. Thus, there is a need to examine different ways of helping women experiencing postnatal depression; encouraging them to exercise may be one way. A meta analysis found some support for exercise as an adjunctive treatment for postnatal depression but the methodological inadequacy of the few small studies included means that it is uncertain whether exercise reduces symptoms of postnatal depression. We aim to determine whether a pragmatic exercise intervention that involves one-to-one personalised exercise consultations and telephone support plus usual care in women with postnatal depression, is superior to usual care only, in reducing symptoms of postnatal depression.

METHODS

We aim to recruit 208 women with postnatal depression in the West Midlands. Recently delivered women who meet the ICD-10 diagnosis for depression will be randomised to usual care plus exercise or usual care only. The exercise intervention will be delivered over 6 months. The primary outcome measure is difference in mean Edinburgh Postnatal Depression Scale score between the groups at six month follow-up. Outcome measures will be assessed at baseline and at six and 12 month post randomisation.

DISCUSSION

Findings from the research will inform future clinical guidance on antenatal and postnatal mental health, as well as inform practitioners working with postnatal depression.

TRIAL REGISTRATION NUMBER

ISRCTN84245563.

Does activity matter: an exploratory study among mothers with preterm infants?

The purpose of this study was to describe the daytime activity levels and their association with sleep, fatigue, depressive symptoms, and quality of life. Wrist actigraphy and questionnaires were used to examine 51 mothers with a preterm infant during their second week postpartum. Circadian activity rhythms (CAR) were less synchronized in these mothers; they experienced sleep disturbances, fatigue, depressive symptoms, and poor health-related quality of life (H-QOL). Compared to high-activity mothers, mothers with low activity levels slept less during nighttime but napped more during daytime, and reported more postpartum depressive symptoms. Further research is needed to examine the effect of low activity level and sleep loss on postpartum depression, and to develop interventions for improving rest/activity patterns for new mothers.

The relationship between compulsive exercise and emotion regulation in adolescents

OBJECTIVE

Compulsive exercise is suggested to be a strategy to regulate emotions. This suggestion has never been studied in adolescents. Therefore, this study examined the cross-sectional association between emotion regulation and compulsive exercise attitudes in adolescents.

DESIGN

A cross-sectional design was employed for this study.

METHOD

A sample of 1,630 adolescent boys and girls completed self-report measures of compulsive exercise, emotion regulation, and disordered eating attitudes, as part of ongoing research into exercise and eating attitudes in adolescents.

RESULTS

Compulsive exercise was significantly associated with emotion regulation, after controlling for disordered eating attitudes. Among boys, compulsive exercise was associated with internal functional, internal dysfunctional, and external functional emotion regulation strategies. In girls, internal functional and internal dysfunctional emotion regulation strategies predicted compulsive exercise.

CONCLUSIONS

Adolescents' compulsivity towards exercise is positively associated with different emotion regulation strategies. More work is needed to identify whether emotion regulation strategies longitudinally predict compulsive exercise.

Physical activity and depressive symptoms among pregnant women: the PIN3 study

Prenatal depression confers health risks for both mother and family. Physical activity may promote better mental health; however, few studies have examined the influence of physical activity on prenatal depression. Data from 1,220 women enrolled in the third Pregnancy, Infection, and Nutrition Study (2001-2005) were used to examine the associations between overall and domain-specific moderate-to-vigorous physical activity (MVPA) and depressive symptoms during pregnancy. Self-reported, past week physical activity assessed at 17-22 weeks' gestation was modeled in logistic regression with self-reported depressive symptoms assessed by the Center for Epidemiologic Studies-Depression Scale at 24-29 weeks' gestation. Active women with ≤2.67 h/week of total MVPA had almost half the odds of having high depressive symptoms as compared to women with no MVPA (odds ratio [OR] = 0.56, 95% confidence interval [CI] = 0.38, 0.83). Increased odds of elevated depressive symptoms were found for women participating in some but ≤2.25 h/week of adult and child care MVPA (OR = 1.84; 95% CI = 1.08, 3.11) and >1 h of indoor household MVPA (OR = 1.63, 95% CI = 0.99, 2.70) when compared to women with no MVPA. While overall MVPA may play a role in reducing the odds of developing elevated depressive symptoms, adult and child care and indoor household activities may increase it.

Postpartum depression: an essential overview for the practitioner

Postpartum depression (PPD) is a cross-cultural form of major depressive disorder that affects some 13% of women and can have serious health consequences for both the mother and her child. Easy-to-use, reliable, self-administered screening tools are available. PPD may have a variety of etiologies, which include changing plasma levels of estrogen and progesterone, postpartum hypothyroidism, sleep deprivation, or difficult life circumstances. Standard treatments for PPD include psychotherapy and antidepressants. However, treatment of a thyroid condition or insomnia, or even regular exercise or massage may also be beneficial. PPD is underdiagnosed, therefore more screening is needed. Obstetricians and pediatricians have a unique opportunity to test women for PPD, but general practitioners may encounter patients with undiagnosed PPD, too. These physicians could positively impact the lives of depressed mothers and their children by identifying them, then treating or providing referrals for care as appropriate.

Treatment of postpartum depression: clinical, psychological and pharmacological options

Postpartum depression (PPD) is a common complication of childbearing, and has increasingly been identified as a major public health problem. Untreated maternal depression has multiple potential negative effects on maternal-infant attachment and child development. Screening for depression in the perinatal period is feasible in multiple primary care or obstetric settings, and can help identify depressed mothers earlier. However, there are multiple barriers to appropriate treatment, including concerns about medication effects in breastfeeding infants. This article reviews the literature and recommendations for the treatment of postpartum depression, with a focus on the range of pharmacological, psychotherapeutic, and other nonpharmacologic interventions.

MobileMums: a randomized controlled trial of an SMS-based physical activity intervention

BACKGROUND

Postnatal women (<12 months postpartum) are at increased risk of physical inactivity.

PURPOSE

To evaluate the efficacy and feasibility of a theory-based physical activity (PA) intervention delivered to postnatal women primarily via mobile telephone short message service (SMS).

METHODS

Eighty-eight women were randomized to the intervention (n = 45) or minimal contact control (n = 43) condition. The 12-week intervention consisted of a face-to-face PA goal-setting consultation, a goal-setting magnet, three to five personally tailored SMS/week and a nominated support person who received two SMS per week. SMS content targeted constructs of social cognitive theory. Frequency (days/week) and duration (min/week) of PA participation and walking for exercise were assessed via self-report at baseline, 6 and 13 weeks.

RESULTS

Intervention participants increased PA frequency by 1.82 days/week (SE +/- 0.18) by 13 weeks (F ((2,85)) = 4.46, p = 0.038) and walking for exercise frequency by 1.08 days/week (SE +/- 0.24) by 13 weeks (F ((2,85)) = 5.38, p = 0.02). Positive trends were observed for duration (min/week) of PA and walking for exercise.

CONCLUSIONS

Intervention exposure resulted in increased frequency of PA and walking for exercise in postnatal women.

Postpartum depression and adolescent mothers: a review of assessment and treatment approaches

Postpartum depression (PPD) affects a significant proportion of adolescent mothers. Adolescence presents unique challenges that may make the young mother more vulnerable than her adult counterparts to PPD. PPD impacts a mother's ability to care for her infant and has been associated with adverse effects on child development. A review of the literature on adolescent PPD was undertaken. The prevalence and the effects of PPD are reviewed, common screening instruments for PPD are compared, and the results of treatment outcome studies are highlighted. There is a need for randomized controlled studies of interventions for adolescents with PPD. Findings from treatment outcome studies with adults with PPD and pregnant adolescents who are depressed suggest that psychosocial interventions may also be effective for adolescents with PPD. Issues in assessment and treatment of PPD among adolescents are considered.

When depression complicates childbearing: guidelines for screening and treatment during antenatal and postpartum obstetric care

Prevalence studies show that 1 in 5 women experience an episode of major depressive disorder during their lifetime. The peripartum period is a prime time for symptom exacerbation and relapse of depressive episodes. Health care providers, specifically those in obstetric care, should be aware of: (1) the frequency of depression in pregnant and postpartum women; (2) signs, symptoms, and appropriate screening methods; and (3) the health risks for the mother and growing fetus if depression is undetected or untreated. Because management of depressed peripartum women also includes care of a growing fetus or breastfeeding infant, treatment may be complex and requires input from a multidisciplinary team, including an obstetrician, psychiatrist, and pediatrician, to provide optimal care.