Unipolar Depression During Pregnancy: Nonpharmacologic Treatment Options

Christopher Tjoa; Emmanuelle Pare; Deborah R Kim

Disclosures

Women's Health. 2010;6(4):565-576. 

In This Article

Exercise

In addition to cardiovascular and general health benefits, there is growing evidence that exercise may help alleviate symptoms of mild depression.[50,51] In nonpregnant depression, randomized controlled studies have compared exercise to a control condition, with five of those trials reporting long-term follow-up data.[52–56] Two recent systematic reviews of exercise therapy have shown modest results, including a recent Cochrane review that found an effect size (measured by standardized mean difference) of -0.82 (95% CI: -1.12– -0.51) for the antidepressant effect of exercise. In the same study, post hoc examination of two trials that compared exercise to antidepressant medication (sertraline) revealed an effect size of -0.04 (95% CI: -0.31–0.24), suggesting therapeutic equivalence in these studies. Sensitivity analysis showed that when the review was limited to trials with adequate allocation concealment, intention-to-treat analysis, and blinded outcome assessment, the effect size of exercise shrank to a statistically insignificant -0.42 (95% CI: -0.88–0.03).[57,58]

There are two studies that examine the mood-elevating properties of exercise during pregnancy (Table 1).[59,60] The first study by Lox et al. enrolled women in the second and third trimester of pregnancy into a 6-week semi-weekly 45-min aquatic exercise class.[59] Women were not selected for or screened for MDD. The authors employed a 12-item Subjective Exercise Experiences Scale, which was comprised of subscales measuring positive wellbeing, psychological distress and fatigue.[61] This study found large effect sizes showing improvement in positive wellbeing, moderate effect sizes on psychological distress, and a large reduction of fatigue in the second trimester, an effect that was less significant in subjects in the third trimester of pregnancy. The second study by Polman et al. studied 66 pregnant women between 22 and 41 years of age in the second or third trimester of pregnancy.[60] Women were chosen from four locations, including women participating in either aqua or studio exercise (the experimental group), or a control condition consisting of women enrolled in parentcraft classes or a routine visit with a general practitioner surgeon. Parentcraft classes were designed to prepare women for labor using relaxation techniques and breathing exercises, and the general practitioner surgery group included women who had received care in a surgery clinic and would be following up. Women were asked to complete a profile of mood state before and after each activity.[62] An increase in overall mood scores was seen for participation in aqua and studio conditions, with post hoc analysis showing aquatic exercise was associated with a decrease in the depression sub-score. Parentcraft classes did not alter mood states, and results from the general practitioner surgery group were not explicitly reported. While both studies reveal mood-elevating properties of antepartum exercise, neither study targeted women diagnosed with MDD, employed objective rating scales of depression or adequately controlled for effects of social support.

As exercise is recommended during pregnancy by the American College of Obstetricians and Gynecologists, the UK Department of Health, and the US Department of Health and Human Services, and healthy lifestyles are encouraged by the combined APA/ACOG treatment guidelines, exercise can be recommended to pregnant women with depression with suggestions that it may have mood-elevating properties. There is currently no evidence that exercise is effective as monotherapy for moderate or severe depressive symptoms or women meeting criteria for MDD during pregnancy. Women who are hesitant to take medication or enter psychotherapy may chose exercise as a treatment for depression, and further study of this option would inform treating clinicians. Published recommendations for exercise during pregnancy are summarized in Table 2, although these recommendations should not replace consultation with an obstetrical provider in cases of concern and for practical suggestions for safe exercises.[28,63–65]

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