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American Journal of Lifestyle Medicine http://ajl.sagepub.


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:

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given that many women discontinue antidepressant medication during pregnancy. however. however. small sample sizes.4% of pregnant women experience depressive symptoms and approximately 12.2 The rate of depression is higher during the first trimester of pregnancy compared with the Exercise may also be preferred relative to antidepressant medication. 209 Cooke Hall. Keywords: pregnancy.2 Depression during pregnancy is a significant predictor of postpartum depression. Copyright © 2011 The Author(s) 370 .nav. University of Minnesota. 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. 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. including lack of randomization. Kennedy. Lewis. Lewis. PhD. exercise.1 Research indicates that 18. the authors review the available studies examining the effect of exercise on mood and depressive symptoms during pregnancy and postpartum.sagepub. Taken together. the studies had significant limitations. University of Minnesota.1177/1559827610392891. Depression During Pregnancy Depression during pregnancy is relatively common and is a significant public second and third trimesters. 2010. and lack of control for contact time. 1900 University Avenue SE. e-mail: blewis@umn. School of Kinesiology. and women may be reluctant to use antidepressant medication if breastfeeding during the postpartum phase. In this article. postpartum. revised March 9. Minneapolis. MN 55455. less is known regarding the efficacy of exercise for treating depression during pregnancy and the postpartum phase. and Betsy F. Minnesota. PhD. Research indicates that exercise is efficacious for treating depression among adults in general. Manuscript received October Minneapolis.American Journal of Lifestyle Medicine July • Aug 2011 Beth A. From the School of Kinesiology. 2010. 2009. physical activity. The authors provide practical suggestions for depression screening and exercise counseling for pregnant and postpartum women.3 High levels of stress and anxiety related to depression during pregnancy are also DOI: 10. depression health problem. For reprints and permissions queries. please visit SAGE’s Web site at http://www. because of the potential benefits of exercise on mood during pregnancy and postpartum and the general health benefits of exercise. Address correspondence to Beth A. accepted April 20. health care providers should encourage their healthy pregnant and postpartum patients to exercise. A majority of these studies indicated that exercise may be beneficial for improving mood.7% experience a major depressive episode during pregnancy. Additional research is needed to better understand the effect of exercise on depression during pregnancy and the postpartum

The psychosocial interventions varied in content and included interpersonal. usually occurs during the first 6 weeks after delivery but can occur up to 6 months following childbirth.13. However. Limitations of this study included a small sample size and no placebo control group. Treatment is typically not required for baby blues. 1 study indicated that fluoxetine was equally effective relative to a cognitive-behavioral intervention for postpartum depression. tearfulness. Cohen and colleagues10 examined the effect of discontinuing antidepressant medication during pregnancy. and generalized anxiety. however.2 However. To ensure safety of the fetus. and not being employed full-time. low income. There are potential ethical reasons for the lack of randomized trials examining the efficacy of antidepressant medication. on the other hand.29 For example.6 In a nonrandomized longitudinal study.25 difficulty caring for the newborn.7 The 10 studies included in the review indicated that the psychosocial intervention reduced levels of depressive symptoms when compared with usual care.33 Additional research is needed to better understand both the safety and effectiveness of antidepressants for the treatment of depression during the postpartum phase. there has been variabil- ity across studies. sleep disturbance. whereas 68% who discontinued their antidepressant medication relapsed. Exercise may be a viable alternative to psychotherapy given that cost.vol. difficulty concentrating.21 Postpartum depression can have a profound effect on both the mother and newborn.15 Baby blues typically occur within the first few days following childbirth and last from a few days to up to 2 weeks.14 Therefore. Specifically. research indicates that negative consequences of postpartum depression include poor functional status of the mother. depressive symptoms must interfere with the daily functioning of the mother and last for at least 2 weeks. and transportation constraints may be potential barriers to psychotherapy. Exercise and Depression One potential intervention that may be effective for treating depression during pregnancy and the postpartum phase is exercise. child care. and suicidal ideation.15 Unlike the baby blues.32. it may be unethical to withhold treatment from pregnant women randomly assigned to a placebo condition.22 increased risk of depression in the future. guilt.30 Similarly. fatigue.”15 Baby blues can involve a mild mood disturbance. this study suggests that there is a need for alternative therapies for depression during pregnancy.26.24. For example. a recent Cochrane review indicates strong support for the efficacy of psychosocial interventions for postpartum depression.11 Therefore. researchers have linked depression during pregnancy to lower neuromotor performance in the newborn. it may be unethical to provide antidepressant medication to pregnant women. postpartum depression often does require treatment.19. it is important to note that the research linking antidepressants to birth defects is not conclusive. Misri and colleagues31 found that paroxetine was equally effective relative to a cognitive behavioral intervention plus paroxetine. nondirected counseling. young maternal age. and telephone-based support. irritability. given 371 . Exercise may also be preferred relative to antidepressant medication. including brief interpersonal therapy and education. Antidepressants are effective for treating general depression8.11 Another potential ethical issue is that if antidepressant medications are effective during pregnancy. A final ethical consideration is the dose of medication. Results indicated that 65 of the 201 women discontinued their antidepressant medication and another 34 reduced their dose. 26% of women who maintained their use of antidepressant medication during pregnancy experienced a relapse of depression during pregnancy. clinicians frequently decrease the dose of antidepressant medication.23 poor infantchild bond. Furthermore. irritability. cognitivebehavioral treatment.6 Similarly. Postpartum depression.5 According to a meta-analysis. loss of appetite.28 Preliminary evidence does indicate that antidepressants may be effective for treating depression during the postpartum phase. given their potential for inducing birth defects. Although definitive conclusions cannot be made given the lack of a randomized controlled design.15 To meet the diagnostic criteria for depression.9.4 Additionally. A general limitation of using antidepressants during the postpartum period is that mothers who are breastfeeding may be reluctant to take antidepressant medication.27 Unfortunately. tearfulness. the efficacy of antidepressants specifically used during pregnancy has not been well studied. this suggests that antidepressant medication may not be as effective during pregnancy if the medication dose is maintained at the same or lower levels. few women with postpartum depression seek treatment.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. given that several studies did not control for various confounding factors.12 However.17 Recent estimates indicate that 10% to 15% of postpartum women experience depression. several types of psychosocial interventions are efficacious for treating depression during pregnancy.22 and adverse effect on the significant other. 5 • no. Depression During Postpartum Phase It is estimated that approximately 30% to 75% of new mothers experience “baby blues. research indicates that using antidepressants during pregnancy may be associated with shorter gestation and birth malformations in the fetus. 4 American Journal of Lifestyle Medicine related to premature labor and low birth weight. 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. with 1 study reporting a rate as high as 36%. inability to cope with the infant.16 Common symptoms include feelings of despondency.1.20 Risk factors for postpartum depression include low education. sleep and appetite disturbance.

Another study used an observational design to examine the relationship between leisure-time exercise and psychological well-being. and personal communications.32. The sample consisted of 66 pregnant women between the ages of 22 and 41 years in their second or third trimester of pregnancy. depression has been linked to imbalances of the hypothalamic–pituitary–adrenal axis. 45 minutes of exercise (ie. Both questionnaires were administered before and after the sessions for both groups. which is particularly problematic given the lack of randomization.35and. and 15 minutes of cool-down. Overview of Literature Review Several sources were used when conducting the literature search for this article.American Journal of Lifestyle Medicine July • Aug 2011 that many women discontinue antidepressant medication during pregnancy. Specific physiological mechanisms may influence the effect of exercise on depression. Participants took the Profile of Mood State Scale (POMS) to assess their mood 10 minutes prior to the class and immediately after the class. 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. and they are summarized in Table 1. The Lubin Depression Adjective Checklist Form C was used to assess depression. stationary cycling. therefore. 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. could also be effective during pregnancy and postpartum. Additionally. Articles that did not focus on how exercise during pregnancy or postpartum affects depression were excluded. In a similar study. We will also provide practical suggestions for screening and managing pregnant and postpartum women who have depression. both lasting 90 minutes. Participants who exercised during the first and second trimesters of pregnancy reported fewer depressive . and exercise plus sertraline were equally efficacious in reducing depressive symptoms both at the end of treatment36 and at follow-up. or physical activity and depression and pregnancy. A total of 320 articles were found through the literature search using the keywords exercise. sertraline. CINAHL. participants who maintained their exercise following treatment were less likely to be depressed at follow-up. For example. (3) parent craft class led by a midwife at a hospital. Furthermore. The major limitation of this study is that participants were not randomized to the various conditions. They were also excluded if they (1) examined the relationship between postpartum depression and weight loss. and (4) were not written in English. (2) studio exercise class. or postpartum. Mood was assessed using the POMS. Results indicated that the exercise classes led to improvements in mood relative to the parent class. both sertraline and an exercise intervention were more efficacious than a placebo for reducing depressive symptoms. Limitations of this study included the small sample size and lack of randomization to the 2 conditions. A final study conducted by Blumenthal and colleagues34 found that among individuals with a major depressive disorder. This article will focus on the remaining 13 articles.33 Research indicates that exercise is effective for treating major depression in adults34. Koltyn41 examined the effect of an exercise program on mood and anxiety among 20 pregnant women. including Pubmed. PsycINFO. and the STAI was used to assess anxiety. participants in the exercise classes reported higher exercise levels than participants in the other conditions.38 For example. 1 study found that exercise. Exercise was assessed using a structured interview examining frequency and duration of exercise. 1 study examining pregnancy during adolescence was excluded. Polman and colleagues40 evaluated the effect of 1 session of exercise on mood among pregnant women.37 Dunn and colleagues35 conducted another randomized trial. and rowing). it has been hypothesized that dysregulation in the central monoamine system may play a role in depression. we will include observational studies as well as randomized controlled trials. given that this population is coping with different stressors from those of adult women. Exercise may reduce depressive symptoms by correcting this imbalance in the central monoamine system.42 Participants (n = 180) were recruited in their first trimester of pregnancy and completed questionnaires throughout their pregnancy. and exercise is linked to an attenuation of the response to stress by this axis. 15 minutes of floor exercises. Specifically. or (4) a control group that did not exercise or participate in the parent craft class. (2) focused on psychobiology only. Our review 372 expands on the recent review conducted by Daley et al39 by evaluating the pregnancy literature in addition to the postpartum literature. The exercise session consisted of a 15-minute warm-up. walking. and women may be reluctant to use antidepressant medication if breastfeeding during the postpartum phase. unlike the Daley et al article. Similarly. The exercise and parent craft classes lasted 45 to 50 minutes. Additionally. Participants either participated in an exercise session or an informational meeting.37 In this same study. Results indicated that the exercise session led to improvements in mood and reduced anxiety relative to the control group. (3) examined exercise prior to pregnancy. The behavioral activation of exercise may serve as the mechanism for reducing depressive symptoms. Participants were assigned to 1 of the following 4 groups: (1) aquanatal exercise class. Another limitation is that it is unclear how long the effect of the intervention persisted. Effect of Exercise on Mood During Pregnancy We identified 4 articles examining the effect of exercise on depression during pregnancy. and anxiety was assessed using the State-Trait Anxiety Inventory (STAI).

Participants completed the STAI and the POMS before and after the session. Ko and colleagues45 examined the effect of multiple exercise sessions on depressive symptoms among postpartum Taiwanese women. This relationship was not found during the third trimester. parent craft class. Limitations of the study included lack of randomization. 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 O’Connor43 12 Pregnant women Observational No correlation between physical activity and mood Abbreviation: POMS. Participants completed the questionnaires after completing 6 classes. symptoms than participants who did not exercise. POMS assessed mood 7-Day Physical Activity Recall Interview. Participants completed the 7-Day Physical Activity Recall Interview. and a short-term follow-up assessment (ie. 5 • no. Results indicated that both anxiety and depression decreased following the exercise and rest sessions. Participants who exercised also reported lower anxiety levels than participants who did not exercise. 3 days per week. The exercise session consisted of 60 minutes of low-impact aerobic activity at 60% to 70% maximal heart rate reserve. Profile of Mood States Scale. The limitation of this study is that exercise was assessed using a self-report measure. 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). Depression was assessed using the Chinese version of the Center for Epidemiological Studies Depression Scale. Poudevigne and O’Connor43 examined the relationship between mood and physical activity among pregnant women (n = 12). In other words. accelerometer. POMS assessed mood Aqua class. or control group. Additionally. All other individuals were assigned to the control group (n = 30). Results indicated no significant correlation between physical activity and mood. Additionally. Another study examined the effect of exercise on physical and mental fatigue 373 . small sample size. yoga movements. the study was observational and therefore causation cannot be inferred. One major limitation of this study is that it was laboratory based and may not generalize to a real-world setting. This result was found for all 3 trimesters of pregnancy.vol. 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. Pilates. wore an accelerometer to objectively measure physical activity. and it is unclear what the effect of multiple exercise sessions would be on mood. and music at 50% to 60% maximal heart rate) were assigned to the exercise group (n = 31). 4 American Journal of Lifestyle Medicine Table 1. The exercise program lasted 1 hour. exercise was related to a decrease in total mood disturbance. 2 months). There were no differences between groups on depressive symptoms. Participants who were willing to participate in the lowintensity exercise program (ie. however. it is possible that participants who experienced lower depression and anxiety were more likely to exercise or vice versa. the sample size was small. which are summarized in Table 2. studio class. and completed the POMS. 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. Participants were randomly assigned to complete 1 exercise session or a quiet rest session.

Edinburgh Postnatal Depression Scale. STAI. which retrospectively assessed health behaviors during pregnancy 12-Week pram walking plus social support sessions. EPDS assessed depression Exercise intervention for 12 weeks (met with exercise physiologist) or control group. Profile of Mood State Scale. EPDS assessed depression Two motivational sessions. 2 support telephone calls (lasted 12 weeks). EPDS assessed depression Participated in 6 low-intensity exercise sessions in 3 weeks. 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. 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. CES-D.American Journal of Lifestyle Medicine July • Aug 2011 Table 2. 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. STAI assessed anxiety. State-Trait Anxiety Inventory. 374 . EPDS assessed depression Two 40-minute pram-walking sessions plus 1 session on own per week for 12 weeks. CES-D assessed depression Exercise was one 60-minute bout. including walking and pedometers. Center for Epidemiological Studies Depression Scale. and POMS assessed depression Randomized to exercise or control group Nonrandomized group comparison Ko et al45 No significant differences between groups on depression scores Anxiety and depression decreased following exercise and rest sessions. POMS. 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 significant 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.

There are several strengths of this study. in that only 3 women in the exercise arm did not complete the home-based exercise sessions. which is an annual assessment conducted by the Centers for Disease Control (n = 2169). and participants were given pedometers. Both the exercise and control arms were given a 3-page postpartum depression booklet and were asked to log their exercise each day. setting goals. There were no differences for mental fatigue at posttreatment. Participants also received 2 support telephone calls. Additionally. coping with barriers. This group met with the other mothers in the study and their children and did not exercise. however. The exercise group reported greater decreases in depressive symptoms relative to the control group at both 6 and 12 weeks. Furthermore. Limitations included a small sample size and the fact that depression was not assessed using a structured interview. The social support control group met once per week for 90 minutes during the 12 weeks.vol. The exercise arm reported a significant decrease in physical fatigue relative to the control group at both posttreatment and 3 months following treatment. 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. Results indicated that there was no correlation between being physically active before and/or during pregnancy and feelings of depression. Limitations included a short-term follow-up. response rates were low. The direct effect of the intervention on depressive symptoms was not reported. The session also included a walking session.46 Participants who were 4 to 38 weeks postpartum (n = 88) and reported depressive symptoms were randomly assigned to an exercise intervention or control. Depression was assessed using the Edinburgh Postnatal Depression survey at 12 weeks (ie. Armstrong and Edwards48 examined the effect of a walking program on postpartum depression among postpartum women who scored 12 or more on the EPDS. and self-report of exercise behavior. 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.51 The data obtained for the study was taken from the Pregnancy Risk Assessment Monitoring System. an exercise prescription. Participants were telephoned once per week to remind them to complete their homebased exercise sessions. 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. Participants in the pram-walking group exhibited improvements in their depressive symptoms relative to the control group at the end of treatment. Daley and colleagues50 examined the feasibility of an exercise intervention for the treatment of postpartum depression. To address these limitations. Participants in the exercise group reported an average of 124 minutes of exercise per week. Participants in the exercise intervention met with an exercise physiologist 4 times over the 12-week intervention.49 The pram-walking program lasted 12 weeks and consisted of 2 group walking sessions per week lasting 40 minutes. Participants were randomized to either a 12-week group-based walking program plus social support or a control group. and relapse prevention. Regarding feasibility. Participants were also given a heart rate monitor to assess their exercise at home and logged their exercise. and a supervised exercise session. both telephone and survey based. The exercise condition consisted of 2 one-on-one consulting sessions focusing on increasing motivation to exercise. 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. 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 randomized to a 12-week exercise condition or usual care. 5 • no. there were no differences in depressive symptoms between the 2 study arms. One major limitation to this study is that it is unclear whether exercise or social support accounts for the effect. Limitations of this study included a small sample size and lack of control for contact time in the usual care arm. the authors were unsuccessful in helping the participants increase their exercise. One limitation is that the control arm did not control for contact time. posttreatment). the authors were successful in recruiting 38 postpartum women. Strengths of this study included the randomized design and high adherence to exercise. Physical activity and mood were self-reported within the overall survey. Therefore. A maximal graded exercise stress test using a treadmill assessed cardiovascular fitness. increasing self-efficacy. Only participants who scored 10 or higher on the Edinburgh Postnatal Depression Scale (EPDS) were included in the study. including a randomized design and an objective assessment of exercise. 375 . using a non-diagnostic tool to assess depression. the control group did not control for contact time. Participants were also instructed to walk once per week on their own time. 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 random assignment and control for contact time. Participants in the control group completed exercise questions monthly during the 12-week intervention phase. 4 American Journal of Lifestyle Medicine among women experiencing postpartum depressive symptoms. Adherence to exercise was high. The 90-minute session included an overview of the benefits of exercise. so it is possible that the contact received by the intervention arm influenced the findings relative to the control 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. 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.

certified nurse midwives. 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. research indicates that exercise might be beneficial for improving mood and anxiety during pregnancy and the postpartum phase. A majority of women see their health care providers several times during pregnancy and should be routinely screened for depression during these visits. The duration of exercise also did not appear to influence the results of the depression scores. 1 study did not examine the effect of the trimester. Regarding the 9 postpartum studies. Taken together. Summary and Conclusions In summary. There were significantly more postpartum studies examining exercise and depression relative to the pregnancy studies. the studies including 20 or more participants found an effect of exercise on mood. Another limitation is that a majority of the pregnancy studies used the POMS to assess mood. Participants (n = 181) were women who had given birth during the week prior to the study. indicating some preliminary evidence that the aqua class may have been more influential on mood than the gym class. postpartum depression can be screened at the 6-week appointment following childbirth and at the newborn’s well-child visits. type of exercise did not appear to have an impact on the effect of exercise on depression. The findings did not appear to vary depending on the trimester of pregnancy.American Journal of Lifestyle Medicine July • Aug 2011 however. and the study including only 12 participants did not find an effect. The PHQ-9 is a short 9-item questionnaire that can be used to assess depression during pregnancy. difficulty concentrating. 5 found an effect of exercise on depression. it appears that there may be a relationship between exercise and mood during pregnancy. 1 study found that a 90-minute aerobic exercise session improved mood. psychomotor changes. and pediatricians are in a unique position to screen for depression during pregnancy and postpartum. 2 were observational and 2 were nonrandomized group designs). whereas others included low-intensity exercise such as yoga and low-intensity stretching. because of a lack of randomization. nurse practitioners.53 Specific items include depressed mood. given that a structured interview is preferred for proper assessment. Either the PHQ-9 or the EPDS can be used to assess postpartum depression. A strength of this study was the large sample size. One limitation of the postpartum studies is that 376 many of the studies used the Edinburgh Depression Inventory to assess depression. randomization. Limitations There were several limitations of the pregnancy and postpartum studies included in this review. Obstetricians. The EPDS was used to assess depressive symptoms.45 Other than this 1 study. More research is needed to further examine this finding. This is problematic. Practical implications are outlined in more detail below.42 The type and duration of exercise also did not appear to alter the findings. however.40 This study also found that the aqua class exhibited lower scores on the depression subscale of the POMS (lower depression). we suggest that practitioners advise their patients to exercise in cases in which exercise is not contraindicated. none of the 4 pregnancy studies reviewed were randomized trials (ie. 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. The EPDS is a 10-item scale specifically designed to assess postpartum . Additionally. and 1 was a nonrandomized group design. low energy.41 Another study found that both an aqua and gym class improved mood as measured by the POMS. primary care clinicians. Because there were only 9 studies examining the effect of exercise on depression during the postpartum phase. and the 1 study not finding an effect had a very small sample size (n = 12). which is a limitation. Abraham and colleagues52 examined the effect of exercise and eating behaviors during pregnancy on depressive symptoms following childbirth. definitive causation cannot be inferred regarding the link between exercise and depression. Regarding the pregnancy studies. additional research is needed.41 another study only included participants in the second and third trimester. given that the POMS is a current measure of mood and does not assess specific depressive symptoms during the previous 2 weeks. Specifically. They completed a structured interview and a questionnaire that retrospectively assessed health behaviors during pregnancy. Several of the studies included walking. diminished pleasure.40 and a third study found an effect of exercise on mood in the first and second trimester but not in the third trimester. and suicidal thoughts. The duration of exercise ranged from 30 to 60 minutes per session across the studies. or type of measure affecting efficacy. it appears that exercise during pregnancy may have a protective effect on postpartum depression. sleep disturbance. First. However. 2 were observational. however. Not surprisingly. self-deprecation. a significant limitation was the small number of survey items assessing physical activity and depression. appetite changes. The study including low-intensity stretching did not find an effect of exercise on depression. Of the 2 studies examining specific types of exercise. additional research using large randomized controlled designs are needed. Of the 3 studies finding an effect. 3 of the 4 studies did find a relationship between exercise and mood. Therefore. 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. 6 of the 9 postpartum studies were randomized trials. There did not appear to be a pattern regarding sample size. Finally.

2004. 7. Lohr KN. In: London MF. Fiori-Cowley A.8:37-54. Gartlehner G. Olson KL. The impact of postpartum depression on mothering.33:323-331. Lundy B. 20. Health care providers could provide exercise prescriptions to women and discuss the benefits of exercise in regard to mood. Cooper P. Furukawa T. Jones N. 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. Trybulski J. and research indicates that exercise might help with depression during pregnancy and the postpartum phase. 22. 25. Acknowledgment This project was supported in part through a grant from the National Institute of Mental Health (MH073820). Comparison of postpartum and nonpostpartum depression: clinical presentation. Williams SB. exercise may be contraindicated. walking groups. Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review. Weinberg MK. Horowitz JA. 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