MINIMIZING DEPRESSION USING THERAPY & EXERCISE 1

Psychotherapy and Exercise Among Postpartum Women to Minimize Depression Risk

Madisyn Rossi

College of Nursing, University of South Florida

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Abstract

Clinical Problem: Postpartum women are at a higher risk for developing symptoms of anxiety

and depression and many new mothers do not find it desirable or feasible to seek traditional care

for their symptoms by taking antidepressant medications.

Objective: The objective of this synthesis is to discuss if using exercise interventions and

psychotherapy sessions can assist in alleviating symptoms of anxiety and depression among

women during the postpartum period. PubMed was used to locate randomized controlled trials

(RCT) supporting the use of talk therapy and exercise to decrease levels of anxiety and

depression. The search terms to locate trials through the database were “postpartum depression”,

“exercise”, “stress”, “psychotherapy”, and “anxiety”.

Results: In postpartum women, those who participated in exercise and psychotherapy sessions

had a decreased risk for developing severe symptoms of anxiety and depression in comparison to

those who did not participate in either of these interventions. Evidence revealed a decrease in

depression and anxiety as measured by the Structured Clinical Interview for DSM-IV (SCID)

and Edinburgh Postpartum Depression Scale (EPDS). It was evidenced that interpersonal

psychotherapy and exercise are not only more accessible methods in alleviating symptoms of

anxiety and depression but may have more of a positive effect on decreasing symptoms in

comparison to pharmacologic therapy with the use of antidepressant medications.

Conclusion: Although exercise and psychotherapy has been shown to decrease severe symptoms

of postpartum anxiety and depression, more research needs to be conducted to assess which type

of exercise and delivery of therapy is most favorable to achieve optimal evidence-based

outcomes.
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Psychotherapy and Exercise Among Postpartum Women to Minimize Depression Risk

Following birth, most women experience stress and approximately 13-19% experience

postpartum depression (Lewis et al., 2021). Many women do not want to seek traditional care for

their depressive symptoms through pharmacologic therapies due to potential stigma or out of fear

that it could be passed to the breastfeeding infant (Lewis et al., 2021). When women do not seek

traditional care, this emotional stress can delay the formation of a bond with their child, which in

turn could create mental health and behavioral issues in the future. In comparison to

antidepressant therapy and basic education provided at hospital discharge, exercise and

psychotherapy have been shown to have several benefits on improving patient anxiety and

depression (Dennis et al., 2020). Therefore, utilizing exercise and psychotherapy interventions

may lessen the severity or prevent development of postpartum depression in postpartum women.

In postpartum women, does the use of physical exercise and psychotherapy, compared to

antidepressant use, affect symptoms of postpartum depression and anxiety?

Literature Search

The scholarly database that was used to locate randomized controlled trials (RCT)

regarding the use of exercise interventions and talk therapy sessions for the alleviation of

postpartum depression and anxiety symptoms was PubMed. The key terms searched on the

database to locate trials were “postpartum depression”, “exercise”, “stress”, “psychotherapy”,

and “anxiety”. In order to find the most recent trials published in the research to evidence the

effectiveness of these interventions on postpartum depression, the publication years searched

were from 2019 to 2021.

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Literature Review

Four RCTs were analyzed to determine the effectiveness of both psychotherapy and

exercise interventions in decreasing symptoms of anxiety and depression in postpartum women.

The clinical guidelines direct healthcare providers to treat postpartum depression with

pharmacologic methods through the use of antidepressant medication (American College of

Obstetricians and Gynecologists’ Committee, 2021). For women that have previously had a

history of depression at any point throughout the course of their life, treatment is recommended

to start right after birth to prevent depression from returning (American College of Obstetricians

and Gynecologists’ Committee, 2021). Drugs are often combined for best results and clinical

guidelines also suggest that women attend support groups at community centers, local hospitals,

and family planning clinics (American College of Obstetricians and Gynecologists’ Committee,

2021). Guidelines briefly touch upon the use of talking with a therapist to discuss and manage

feelings following delivery for weeks, months, or longer depending on the severity of symptoms

(American College of Obstetricians and Gynecologists’ Committee, 2021).

In a randomized controlled trial, Dennis et al. (2020) demonstrated that nurse-delivered

telephone interpersonal psychotherapy is a more accessible method to decrease postpartum

depression symptoms in comparison to traditional interventions such as medication and in-

person therapy sessions. Depressive symptoms were measured by the SCID and EPDS. Patients

in the intervention group participated in 12, 60-minute nurse-delivered telephone interpersonal

psychotherapy sessions. Those in the control group did not receive any interpersonal

psychotherapy and received usual care. There were 241 postpartum women selected between 2-4

weeks postpartum, with an EPDS score >12 and discharged at home with their infant. Out of the
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241 women originally selected, 204 completed the trial and 37 women were not able to follow

through. There were 104 participants that received interpersonal psychotherapy and 100 in the

control group. It was evidenced that those who participated in telephone sessions were 4.5 times

less likely to be clinically depressed (p=0.07). Following the trial at 12 weeks, 35% in the control

group remained depressed, whereas only 10.6% of women that received psychotherapy did.

Also, 51% of the control group had an EPDS >12 following the trial in comparison to 21.2% of

women in the psychotherapy group. Strengths of the study included participants being

randomized into control and experimental groups, reliable and valid instruments were used,

follow-up assessments were performed, subjects did not have statistically significant differences,

and the study was not conducted in one study site. Weaknesses of the study included assignment

not being concealed from individuals or providers and not all participants completed the trial.

Other weaknesses include no reasoning for participants not completing the study and possibility

for underreported or overreported symptoms of depression.

In another RCT, Lewis et al. (2021) studied the effectiveness that wellness interventions

and exercise have on postpartum depression and perceived stress among 450 women put into

three conditions: telephone wellness and support intervention, telephone exercise intervention,

and usual care. Depressive symptoms were determined by the SCID that was conducted by a

research assistant under a licensed psychologist. The EPDS was used to assess depression

symptoms and a 14-item Perceived Stress Scale was used to assess stress that the women

experienced. Exercise was assessed using the ActiGraph to measure movement of the person

wearing it and 7-Day Physical Activity Interview. The telephone exercise intervention comprised

of 11 separate sessions, with aim to have participants engage in exercise for at least 30 minutes,
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five days per week. The exercise intervention was created to motivate participants to incorporate

more exercise into their daily schedules by educating on the benefits, social support, and

enjoyment that it can provide. These two interventions provided psychotherapy by allowing

participants to verbalize their feelings about how they felt during the postpartum period. Lastly,

the usual care group was educated on topics related to well-being and health such as coping with

fatigue, time management, healthy sleep, and stress prevention. The wellness and support

intervention can be comparable to the teaching that is standard to be provided to postpartum

women prior to hospital discharge. Depressive symptoms were significantly lower measured by

the EPDS among participants in the exercise and wellness groups, compared to the usual care

group 6 months after the trial (p=0.04). It was also found that stress levels were reduced among

participants in the exercise and wellness interventions in comparison to the usual care category.

Strengths included participant randomization into control and experimental groups, all of the

subjects finished the study, and it was not conducted in a single study site. Some other strengths

include the instruments measuring the outcomes were both reliable and valid, subjects being

blind to the study group, and participants in in each of the groups having no statistically

significant baseline clinical variables. Weaknesses include the sample size being too large, the

study not being conducted in-person, possibility for underreported or overreported exercise, and

follow-up assessments were not conducted.

In the next RCT, O’Hara et al. (2019) examined the effectiveness of psychotherapy and

sertraline in comparison to a pill placebo for women affected by postpartum depression. The trial

was performed at the University of Iowa and Women and Infants Hospital in Rhode Island over a

course of twelve weeks. Symptoms of depression were assessed by both self-reported and
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interview-based measures at baseline, 4 weeks, 8 weeks, and 12 weeks of treatment using

Structured Clinical Interview, Patient Health Questionnaire (PHQ-9), and Hamilton Rating Scale

for Depression. The interviews were administered by research assistants that were blinded to

treatment conditions. The twenty to thirty minutes long interview sessions included questioning

about presenting symptoms, encouraging to comply with the medication regimen, collecting any

medication that had not been taken, asking about side effects, and assessing the use of other

medications. The sample size was 162 women suffering from a major depressive episode during

the first postpartum year randomized into three groups. There were 53 women in the

interpersonal psychotherapy group, 56 women in the sertraline group, and 53 women in the pill

placebo group. The women had to have a DSM-IV diagnosis of Major Depressive Episode using

the Structured Clinical Interview, Hamilton Rating Scale for Depression of 15 or greater, and

between 18-50 years of age (at least 36-weeks’ gestation). Participants taking sertraline and

placebo pills saw minimal improvements in depressive symptoms in comparison to those that

participated in the interpersonal psychotherapy sessions (p=0.02). Strengths included

randomization of participants into groups, random assignment being concealed from participants,

and subjects and providers being blinded to the study (other than those providing IPT). Other

strengths included instruments used to measure were both reliable and valid, subjects had no

differences that were statistically significant, follow-up assessments were conducted, and the

study was conducted in two study sites. Weaknesses were that not all participants began

treatment, not all subjects completed the study, no reasoning was given for the participants that

did not finish the study, and there may have been an underreporting or overreporting of

depressive symptoms.
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Exercise interventions were further assessed by Özkan et al. (2020) to reduce severity of

postpartum anxiety and depression. The study was performed in a south-eastern Turkey

maternity hospital between 2017 and 2018. Depressive symptoms were measured using the

EPDS. Eligibility was determined based on women having a full-term spontaneous vaginal

delivery, having a score of 13 or above on the EPDS, 20-35 years of age, and having a newborn

of weighing at least 2500g. The sample size was 65 women, 34 were selected for the intervention

group and 31 women for the control group. Participants in the intervention group were educated

on the exercises to be conducted and were told to perform exercise five days per week, at least a

half hour daily. Exercises were performed for a total of four weeks during the first postpartum

month and the control group did not exercise and received standard care. The control group

(15.74+/-2.35) and EPDS pre-trial (16.41+/-1.61) mean depression scores were similar. In

comparison, EPDS post-trial scores evidenced significant differences of participants (7.29+/-

1.67) compared to the control (12.54+/-2.65) following the four-week exercise program.

Participants that exercised during the postpartum period had lower EPDS symptoms and had

decreased physical and mental tiredness as well as increased mother’s well-being (p=0.06).

Strengths included participants being randomly assigned, random assignment being concealed

from subjects, and all subjects were able to complete the study. Other strengths include

instruments being used to measure were both reliable and valid, and the subjects did not have

any significant differences. Some weaknesses were that there were no follow-up assessments

conducted after the first four weeks, both providers and subjects were not blind to the study

groups, no rationale was provided for the woman not wanting to participate, and it was

conducted in a single study site.

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Synthesis

From the studies reviewed, evidence demonstrated that patients in either interpersonal

psychotherapy or exercise intervention groups had a significant reduction in symptoms of

depression and anxiety during the postpartum period. First, Dennis et al. (2020) showed that after

the intervention group completed 12, 60-minute nurse-delivered telephone therapy sessions, they

were 4.5 times less likely to be diagnosed clinically depressed than the usual care group

(p=0.07). Second, Lewis et al. (2021) showed that depressive symptoms were significantly less

among participants in exercise and wellness groups, compared to the usual care group at 6

months after the trial (p=0.04). Likewise, Özkan et al. (2020) showed that participants that

exercised during the postpartum period had lower EPDS symptoms and had decreased physical

and mental tiredness as well as increased well-being (p=0.06). In the fourth RCT, O’Hara et al.

(2019) supported these findings by demonstrating that participants taking antidepressants saw

minimal improvements in depressive symptoms in comparison to those that participated in the

interpersonal psychotherapy sessions (p=0.02).

The major weakness of many of these studies was the exclusion criteria of participants.

For example, Dennis et al. (2020) excluded participants if they were non-English speakers and

Özkan et al. (2020) excluded participants if they did not have a spontaneous vaginal delivery.

Also, none of the studies assessed which type of exercise and delivery of therapy is most

favorable for optimal outcomes. Further studies should be conducted with intervention groups

completing different types of exercise, varying from low-intensity to high-intensity. Further

studies should also compare how telephone interpersonal psychotherapy sessions, in-person

sessions, and support groups benefit participants and their symptoms of postpartum depression.
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Clinical Recommendations

Evidence from the research suggests that pharmacologic therapy through the use of

antidepressant medication is an effective method to reduce the severity of anxiety and depression

among postpartum women. The clinical guidelines are beginning to suggest using non-

pharmacologic strategies by attending support groups at local hospitals, family planning clinics,

and community centers or discussing and managing feelings of depression with a mental health

professional (American College of Obstetricians and Gynecologists’ Committee, 2021). The use

of alternative methods such as exercise and interpersonal psychotherapy in postpartum women

could be a low-risk and easily accessible way to alleviate symptoms of depression and anxiety.

Further research is needed to examine which types of exercise and methods of delivery will lead

to the best outcomes. Since exercise and talk therapy does not have any adverse effects, it can be

implemented as an adjunct therapy across clinical settings to promote non-pharmacological

methods opposed to antidepressant therapy. Since postpartum women often are not willing to

take pharmacologic interventions to help with their postpartum depression, this will hopefully

lead to more willingness to follow these interventions and better evidence-based practice

outcomes.
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References

American College of Obstetricians and Gynecologists’ Committee. (2021). Postpartum

depression. American College of Obstetricians and Gynecologists.

https://www.acog.org/womens-health/faqs/postpartum-depression

Dennis, C. L., Grigoriadis, S., Zupancic, J., Kiss, A., & Ravitz, P. (2020). Telephone-based

nurse-delivered interpersonal psychotherapy for postpartum depression: Nationwide

randomized controlled trial. The British Journal of Psychiatry: The Journal of Mental

Science, 216(4), 189-196. https://doi.org/10.1192/bjp.2019.275

Lewis, B.A., Schuver, K., & Dunsiger, S. (2021). Randomized trial examining the effect of

exercise and wellness intervention on preventing postpartum depression and perceived

stress. BMC Pregnancy Childbirth, 21(785), 350-365. https://doi.org/10.1186/s12884-

021-04257-8

O’Hara, M.W., Pearlstein, T., Stuart, S., Long, J. D., Mills, J.A., & Zlotnick, C. (2019). A

Placebo-controlled treatment trial of sertraline and interpersonal psychotherapy for

postpartum depression. Journal of Affective Disorders, 245(83), 524-532.

https://doi.org/10.1016/j.jad.2018.10.361

Özkan, S. A., Kücükkelepce, D. S., Korkmaz, B., Yılmaz, G., & Bozkurt, M. A. (2020). The

effectiveness of an exercise intervention in reducing the severity of postpartum

depression: A randomized controlled trial. Perspectives in Psychiatric Care, 56(4), 844-

850. https://doi.org/10.1111/ppc.12500