The Role of Exercise in Treating Postpartum Depression

Results

The Effects of Exercise Upon Postpartum Depression: Randomised Controlled Trials

In a pilot RCT^[20] in Australia, the effects of a 12-week multi-intervention programme involving group pram walking exercise sessions (3 times per week) plus social support (once per week) was compared with a control group who were asked to maintain their usual exercise regime and social activities. Participants were recruited via recommendations from health professionals or adverts in the community (N = 10 in both groups). Women had to have given birth in the past 12 months and have a score of 12 or more on the Edinburgh Postnatal Depression Scale (EPDS),^[21] which is indicative of probable depression. In both groups, approximately half of the women were receiving medication for their depression and a small number were receiving counselling. Assessments of postpartum depression (using the EPDS), general psychological well-being, anxiety, perceived social support, and aerobic fitness were included in the study. Randomisation was by sealed envelope. It is not clear from the report whether intention to treat analyses were used.

No significant difference in mean EPDS score between groups at baseline was found (pram walking = 17.4; control = 18.4), but the women in the pram walking group exhibited significantly lower EPDS scores than the women in the control group at both the 6-week mid-point (pram walking = 7.2; control = 13.5, P < .01) and at the end of the 12-week intervention (pram walking = 4.6; control = 14.8, P < .01). The women in the intervention group were also found to have significantly improved aerobic fitness post-intervention compared to the women in the control group (P < .01). Adherence to the intervention was acceptable; on average, women attended 24 of the 36 sessions. At baseline, many participants were receiving medication or psychological therapy for their postpartum depression, but were still reporting depressive symptoms.

In the second trial^[22] by the same research team, the effect of a twice-weekly, group-based "pram walking" intervention was compared with the effects seen in a group who received a social support intervention. To be eligible, women had to have a child between the ages of 6 weeks and 18 months of age and score 12 or above on the EPDS.^[21] Twenty-four women were recruited and randomly allocated using opaque envelopes to each trial group. The researchers recruited 10 participants, five of these by a specialist psychiatrist, with the remainder (n = 14) recruited through hospitals, newspaper and television advertisements, and community flyers. Of the women who were recruited, between 50% and 55% were receiving counselling, and between 55% and 60% were taking antidepressants; the number using both treatments was not stated. Outcome measures were postpartum depression (using the EPDS), perceived social support, and aerobic fitness. Five participants withdrew within the first 2 weeks, and data is reported for the 19 who completed the trial (pram walking group: n = 9/12; social support group n = 10/12). Baseline mean EPDS scores were similar (exercise = 17.3; social support = 17.2). For the women in the exercise group, the score decreased significantly by the end of the 12-week intervention period, but not for the women in the social support group (exercise = 6.3; social support = 13.3, P < .05). No significant changes in perceived levels of social support were noted for either group. Significant increases in aerobic fitness (P < .01) were also reported for the women in the exercise intervention group but not for the women in the social support group. Adherence was 75% and 73% for the exercise intervention and control groups, respectively.

While both trials reported substantial reductions in EPDS scores in participants randomised to receive an intervention involving exercise, the small sample sizes and short-term follow-up limit their validity. The long-term merits of the interventions were not assessed. In addition, because both studies were conducted in the Gold Coast, Australia, where the prevailing warm weather conditions are likely to have positively influenced mothers' decisions to exercise by pushing their child in a pram, the generalisability of findings needs to be confirmed. Although initial trial evidence is promising, it is not entirely clear at present whether exercise in the form of pram walking, or indeed any other form of exercise, is effective in women with postpartum depression.

Uncontrolled and Observational Studies Focussing on Postpartum Depression

The efficacy of group-based weekly exercise classes for sedentary women (aged 19-37 years) experiencing postpartum depression referred by health visitors, general practitioners, and a specialist consultant psychiatrist was assessed in Scotland through maternal report.^[23] Evaluation questionnaires were sent to 10 of 20 women who participated in the classes. Most women reported improvements in well-being from the exercise classes, and half said that they also exercised at home. The opportunity for discussion with other mothers, however, was rated higher than both exercise and relaxation as an activity that improved feelings of well-being. The author reports that the final EPDS scores for participants showed a marked reduction (no data presented). An evaluation survey^[24] of a pilot scheme aimed to facilitate exercise opportunities in women at high risk for depression (assessment risk not given) and to mothers (N = 60) living in a socioeconomically deprived area in the north of England found participants reported more energy (n = 19), motivation (n = 21), increased self-confidence (n = 14), feeling more relaxed (n = 17), being more physically active (n = 20), and feeling fitter afterwards (n = 23). A larger study^[25,26] involving a focus group of 50 women, two-thirds of whom were depressed, found that about half of participants felt that depressed mothers would be unlikely to want to get involved in community walking programmes because of concerns about being labelled.

Uncontrolled and Observational Studies

Several additional surveys of mothers' views about the feasibility and perceived effectiveness of exercise programmes after giving birth have been published recently. An Australian "Stroll Your Way To Well-Being" programme for postpartum women^[25] conducted a random telephone survey of the perceived benefits and barriers associated with pram walking (N = 450). About 90% of respondents felt that pram walking could increase physical fitness and improve mental health, and most women (70%) were still walking 16 months after the programme had started.^[26] In another survey^[27] of a group of postpartum women in Australia, opinions about benefit to mental and physical health were surveyed during participation in a pram walking programme. Opinions about benefit were positive but were based on only a 34% response rate. A secondary analysis of longitudinal data^[28] collected prenatally and 6 weeks postpartum from a study of obstetric outcomes in the South of England, found that vigorously active women at the 6-week assessment (N = 1,003) demonstrated better scores on all measures of postnatal adaptation (e.g., confidence in tasks of mothering, satisfaction with life circumstances, and satisfaction with motherhood) and were more likely to participate in activities such as socializing, hobbies, and entertainment. Nine women completed a questionnaire evaluation after taking part in a programme called "Shape Up After Your Baby."^[29] The main reasons for joining the class were to get fit (n = 8) and to meet other mothers (n = 5). When asked what they had enjoyed most about the classes, most women stated meeting other mothers with babies (n = 6), ideas for exercise (n = 6), and opportunities for discussion (n = 6). It is not clear from this report if any mothers had been diagnosed with postpartum depression. A recent study^[30] evaluated the effects of a pram walking intervention upon physical activity, mental health, and social outcomes in volunteers from Australia. Those mothers living an intervention area were invited to participate in a pram walking group (N = 60), and the control group (N = 48) was invited to participate in a pram walking group starting 6 months later. Participants completed an assessment of outcomes by questionnaire at baseline and 6 months after completing the programme. There was no significant increase in the proportion of mothers considered to be performing adequate physical activity in the intervention or control groups from baseline to follow-up. However, intervention group mothers increased their sessions of vigorous exercise and control group mothers increased the amount of minutes spent walking. The majority of mothers had joined a pram-walking group to participate in exercise, get out of the house, and meet other postpartum women.

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