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 DOI: 10.1177/1559827610392891

2011 5: 370AMERICAN JOURNAL OF LIFESTYLE MEDICINEBeth A. Lewis and Betsy F. Kennedy

Effects of Exercise on Depression During Pregnancy and Postpartum: A Review  

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370

American Journal of Lifestyle Medicine July • Aug 2011

Effects of Exercise on Depression During Pregnancy and Postpartum: A Review

Beth A. Lewis, PhD, and Betsy F. Kennedy, MA

DOI: 10.1177/1559827610392891. Manuscript received October 15, 2009; revised March 9, 2010; accepted April 20, 2010. From the School of Kinesiology, University of Minnesota, Minneapolis, Minnesota. Address correspondence to Beth A. Lewis, PhD, School of Kinesiology, University of Minnesota, 1900 University Avenue SE, 209 Cooke Hall, Minneapolis, MN 55455; e-mail: blewis@umn.edu.

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Abstract: Approximately 13% of pregnant women and 10% to 15% of postpartum women report depres-sion. Research indicates that exercise is efficacious for treating depression among adults in general; however, less is known regarding the efficacy of exercise for treating depression during pregnancy and the postpartum phase. In this article, the authors review the available studies examining the effect of exercise on mood and depressive symptoms during pregnancy and post-partum. The authors identified 4 stud-ies examining the effect of exercise on mood during pregnancy and 9 stud-ies examining exercise and depression in the postpartum phase. A majority of these studies indicated that exercise may be beneficial for improving mood; however, the studies had significant limitations, including lack of random-ization, small sample sizes, and lack of control for contact time. Additional research is needed to better understand the effect of exercise on depression dur-ing pregnancy and the postpartum phase. Taken together, because of the potential benefits of exercise on mood during pregnancy and postpartum and the general health benefits of exercise, health care providers should encourage their healthy pregnant and postpartum

patients to exercise. The authors provide practical suggestions for depression screening and exercise counseling for pregnant and postpartum women.

Keywords: pregnancy; postpartum; exercise; physical activity; depression

Depression During Pregnancy

Depression during pregnancy is rela-tively common and is a significant public

health problem.1 Research indicates that 18.4% of pregnant women experience depressive symptoms and approximately 12.7% experience a major depressive episode during pregnancy.2 The rate of depression is higher during the first tri-mester of pregnancy compared with the

second and third trimesters.2 Depression during pregnancy is a significant pre-dictor of postpartum depression.3 High levels of stress and anxiety related to depression during pregnancy are also

Exercise may also be preferred relative to antidepressant

medication, given that many women discontinue antidepressant

medication during pregnancy, and women may be reluctant to use

antidepressant medication if breastfeeding during the

postpartum phase.

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related to premature labor and low birth weight.4 Additionally, researchers have linked depression during pregnancy to lower neuromotor performance in the newborn.5

According to a meta-analysis, several types of psychosocial interventions are efficacious for treating depression dur-ing pregnancy, including brief interper-sonal therapy and education.6 Similarly, a recent Cochrane review indicates strong support for the efficacy of psychosocial interventions for postpartum depression.7 The 10 studies included in the review indicated that the psychosocial interven-tion reduced levels of depressive symp-toms when compared with usual care. The psychosocial interventions varied in con-tent and included interpersonal, cognitive- behavioral treatment; nondirected coun-seling; and telephone-based support.

Antidepressants are effective for treating general depression8,9; however, the effi-cacy of antidepressants specifically used during pregnancy has not been well stud-ied.6 In a nonrandomized longitudinal study, Cohen and colleagues10 examined the effect of discontinuing antidepressant medication during pregnancy. Results indicated that 65 of the 201 women dis-continued their antidepressant medica-tion and another 34 reduced their dose. Furthermore, 26% of women who main-tained their use of antidepressant med-ication during pregnancy experienced a relapse of depression during preg-nancy, whereas 68% who discontinued their antidepressant medication relapsed. Although definitive conclusions cannot be made given the lack of a randomized controlled design, this study suggests that there is a need for alternative therapies for depression during pregnancy.

There are potential ethical reasons for the lack of randomized trials examin-ing the efficacy of antidepressant medi-cation. For example, research indicates that using antidepressants during preg-nancy may be associated with shorter gestation and birth malformations in the fetus.11 Therefore, it may be unethi-cal to provide antidepressant medication to pregnant women, given their poten-tial for inducing birth defects. However, it is important to note that the research

linking antidepressants to birth defects is not conclusive, given that several stud-ies did not control for various confound-ing factors.11 Another potential ethical issue is that if antidepressant medications are effective during pregnancy, it may be unethical to withhold treatment from pregnant women randomly assigned to a placebo condition. A final ethical con-sideration is the dose of medication. To ensure safety of the fetus, clinicians fre-quently decrease the dose of antidepres-sant medication.12 However, 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 clear-ance.13,14 Therefore, this suggests that antidepressant medication may not be as effective during pregnancy if the medi-cation dose is maintained at the same or lower levels.

Depression During Postpartum Phase

It is estimated that approximately 30% to 75% of new mothers experience “baby blues.”15 Baby blues can involve a mild mood disturbance, irritability, sleep and appetite disturbance, tearfulness, and generalized anxiety.15 Baby blues typi-cally occur within the first few days fol-lowing childbirth and last from a few days to up to 2 weeks. Treatment is typically not required for baby blues. Postpartum depression, on the other hand, usually occurs during the first 6 weeks after delivery but can occur up to 6 months following childbirth.15 Unlike the baby blues, postpartum depres-sion often does require treatment.15 To meet the diagnostic criteria for depres-sion, depressive symptoms must interfere with the daily functioning of the mother and last for at least 2 weeks.16 Common symptoms include feelings of despon-dency, guilt, loss of appetite, sleep dis-turbance, tearfulness, inability to cope with the infant, fatigue, irritability, diffi-culty concentrating, and suicidal ideation.17 Recent estimates indicate that 10% to 15% of postpartum women experience depres-sion.1,2 However, there has been variabil-

ity across studies, with 1 study reporting a rate as high as 36%.18 Research indi-cates 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.19,20 Risk factors for postpartum depression include low edu-cation, low income, young maternal age, and not being employed full-time.21

Postpartum depression can have a pro-found effect on both the mother and newborn. Specifically, research indicates that negative consequences of postpar-tum depression include poor functional status of the mother,22 increased risk of depression in the future,23 poor infant-child bond,24,25 difficulty caring for the newborn,22 and adverse effect on the significant other.26,27 Unfortunately, few women with postpartum depression seek treatment.28

Preliminary evidence does indicate that antidepressants may be effective for treat-ing depression during the postpartum phase.29 For example, 1 study indicated that fluoxetine was equally effective rela-tive to a cognitive-behavioral intervention for postpartum depression.30 Similarly, Misri and colleagues31 found that par-oxetine was equally effective relative to a cognitive behavioral intervention plus paroxetine. Limitations of this study included a small sample size and no pla-cebo control group. A general limitation of using antidepressants during the post-partum period is that mothers who are breastfeeding may be reluctant to take antidepressant medication.32,33 Additional research is needed to better understand both the safety and effectiveness of anti-depressants for the treatment of depres-sion during the postpartum phase.

Exercise and Depression

One potential intervention that may be effective for treating depression during pregnancy and the postpartum phase is exercise. Exercise may be a viable alter-native to psychotherapy given that cost, child care, and transportation constraints may be potential barriers to psychother-apy. Exercise may also be preferred rel-ative to antidepressant medication, given

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that many women discontinue antide-pressant medication during pregnancy, and women may be reluctant to use anti-depressant medication if breastfeeding during the postpartum phase.32,33

Research indicates that exercise is effec-tive for treating major depression in adults34,35and, therefore, could also be effective during pregnancy and postpar-tum. For example, 1 study found that exercise, sertraline, and exercise plus ser-traline were equally efficacious in reduc-ing depressive symptoms both at the end of treatment36 and at follow-up.37 In this same study, participants who maintained their exercise following treatment were less likely to be depressed at follow-up.37 Dunn and colleagues35 conducted another randomized trial, which found that indi-viduals who exercised at least 5 days per week for 30 minutes or more each ses-sion experienced reductions in their mild or moderate symptoms of depression. A final study conducted by Blumenthal and colleagues34 found that among indi-viduals with a major depressive disorder, both sertraline and an exercise interven-tion were more efficacious than a placebo for reducing depressive symptoms.

The behavioral activation of exercise may serve as the mechanism for reduc-ing depressive symptoms. Specific phys-iological mechanisms may influence the effect of exercise on depression.38 For example, it has been hypothesized that dysregulation in the central monoamine system may play a role in depression. Exercise may reduce depressive symp-toms by correcting this imbalance in the central monoamine system. Similarly, depression has been linked to imbalances of the hypothalamic–pituitary–adrenal axis, and exercise is linked to an attenua-tion of the response to stress by this axis. More research is needed to better under-stand the exact physiological mecha-nism 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. Our review

expands on the recent review conducted by Daley et al39 by evaluating the preg-nancy literature in addition to the post-partum literature. Additionally, unlike the Daley et al article, we will include observational studies as well as random-ized controlled trials. We will also pro-vide practical suggestions for screening and managing pregnant and postpartum women who have depression.

Overview of Literature Review

Several sources were used when con-ducting the literature search for this arti-cle, including Pubmed, PsycINFO, CINAHL, and personal communications. A total of 320 articles were found through the literature search using the keywords exercise, or physical activity and depres-sion and pregnancy, or postpartum. Articles that did not focus on how exer-cise during pregnancy or postpartum affects depression were excluded. They were also excluded if they (1) exam-ined the relationship between postpartum depression and weight loss, (2) focused on psychobiology only, (3) examined exercise prior to pregnancy, and (4) were not written in English. Additionally, 1 study examining pregnancy during ado-lescence was excluded, given that this population is coping with different stress-ors from those of adult women. This arti-cle will focus on the remaining 13 articles.

Effect of Exercise on Mood During Pregnancy

We identified 4 articles examining the effect of exercise on depression dur-ing pregnancy, and they are summa-rized in Table 1. Specifically, Polman and colleagues40 evaluated the effect of 1 session of exercise on mood among pregnant women. The sample consisted of 66 pregnant women between the ages of 22 and 41 years in their second or third trimester of pregnancy. Participants were assigned to 1 of the following 4 groups: (1) aquanatal exercise class, (2) studio exercise class, (3) parent craft class led by a midwife at a hospital, or (4) a control group that did not exercise or participate in the parent craft class.

The exercise and parent craft classes lasted 45 to 50 minutes. Participants took the Profile of Mood State Scale (POMS) to assess their mood 10 minutes prior to the class and immediately after the class. Results indicated that the exercise classes led to improvements in mood relative to the parent class. The major limitation of this study is that participants were not randomized to the various conditions. Furthermore, participants in the exercise classes reported higher exercise levels than participants in the other conditions, which is particularly problematic given the lack of randomization. Another lim-itation is that it is unclear how long the effect of the intervention persisted.

In a similar study, Koltyn41 examined the effect of an exercise program on mood and anxiety among 20 pregnant women. Participants either participated in an exercise session or an informa-tional meeting, both lasting 90 min-utes. The exercise session consisted of a 15-minute warm-up, 45 minutes of exer-cise (ie, walking, stationary cycling, and rowing), 15 minutes of floor exercises, and 15 minutes of cool-down. Mood was assessed using the POMS, and anx-iety was assessed using the State-Trait Anxiety Inventory (STAI). Both ques-tionnaires were administered before and after the sessions for both groups. Results indicated that the exercise session led to improvements in mood and reduced anxiety relative to the control group. Limitations of this study included the small sample size and lack of randomiza-tion to the 2 conditions.

Another study used an observational design to examine the relationship between leisure-time exercise and psycho-logical well-being.42 Participants (n = 180) were recruited in their first trimester of pregnancy and completed questionnaires throughout their pregnancy. The Lubin Depression Adjective Checklist Form C was used to assess depression, and the STAI was used to assess anxiety. Exercise was assessed using a structured inter-view examining frequency and duration of exercise. Participants who exercised during the first and second trimesters of pregnancy reported fewer depressive

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symptoms than participants who did not exercise. This relationship was not found during the third trimester. Participants who exercised also reported lower anx-iety levels than participants who did not exercise. This result was found for all 3 trimesters of pregnancy. The limitation of this study is that exercise was assessed using a self-report measure. Additionally, the study was observational and there-fore causation cannot be inferred. In other words, it is possible that partici-pants who experienced lower depression and anxiety were more likely to exercise or vice versa.

Poudevigne and O’Connor43 exam-ined the relationship between mood and physical activity among pregnant women (n = 12). Participants completed the 7-Day Physical Activity Recall Interview, wore an accelerometer to objectively measure physical activity, and completed the POMS. Results indicated no signifi-cant correlation between physical activity and mood. 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 depres-sion, which are summarized in Table 2. 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). Participants were randomly assigned to complete 1 exercise session or a quiet rest session. Participants completed the STAI and the POMS before and after the session. The exercise session consisted of 60 minutes of low-impact aerobic activity at 60% to 70% maximal heart rate reserve. Results indicated that both anxiety and depression decreased following the exer-cise and rest sessions; however, exercise was related to a decrease in total mood disturbance. One major limitation of this study is that it was laboratory based and may not generalize to a real-world set-ting. Additionally, the sample size was small, and it is unclear what the effect of

multiple exercise sessions would be on mood.

Ko and colleagues45 examined the effect of multiple exercise sessions on depressive symptoms among postpar-tum Taiwanese women. Participants who were willing to participate in the low-intensity exercise program (ie, Pilates, yoga movements, and music at 50% to 60% maximal heart rate) were assigned to the exercise group (n = 31). All other individuals were assigned to the con-trol group (n = 30). The exercise pro-gram lasted 1 hour, 3 days per week. Participants completed the questionnaires after completing 6 classes. Depression was assessed using the Chinese ver-sion of the Center for Epidemiological Studies Depression Scale. There were no differences between groups on depres-sive symptoms. Limitations of the study included lack of randomization, small sample size, and a short-term follow-up assessment (ie, 2 months).

Another study examined the effect of exercise on physical and mental fatigue

Table 1.

Effect of Exercise on Mood During Pregnancy

Study Participants Exercise and Assessment Study Design Findings

Da Costa et al42 180 Pregnant women

Structured interviews during each trimester and questionnaires completed each month

Observational Exercise resulted in fewer depressive symptoms

Koltyn41 20 White/ pregnant women

90-Minute aerobic exercise session or 90-minute information session for 6 sessions; POMS assessed mood

Nonrandomized group comparison

State-anxiety and depressive symptoms lower in exercise group

Polman et al40 66 Pregnant women

Aqua class, studio class, parent craft class, or control group; POMS assessed mood

Nonrandomized group comparison

Exercise class had higher mood scores

Poudevigne and O’Connor43

12 Pregnant women

7-Day Physical Activity Recall Interview, accelerometer; POMS assessed mood

Observational No correlation between physical activity and mood

Abbreviation: POMS, Profile of Mood States Scale.

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Table 2.

Effect of Exercise on Mood During the Postpartum Phase

Study Participants Exercise and Assessment Study Design Findings

Abraham et al52

181 Healthy women who had given birth the week before

Interview and questionnaire in postnatal week, which retrospectively assessed health behaviors during pregnancy

Observational Exercising for body shape and weight reasons in early pregnancy related to less depressive symptoms during postpartum

Armstrong and Edwards48

20 Postpartum women who screened positive for depression

12-Week pram walking plus social support sessions; EPDS assessed depression

Randomized to pram walking program plus social support or control

Pram walking plus social support group had greater reduction in depressive symptoms

Armstrong and Edwards49

24 Women who had given birth during the previous 12 months and screened positive for depression

Two 40-minute pram-walking sessions plus 1 session on own per week for 12 weeks; EPDS assessed depression

Randomized to pram-walking program or social support control

Pram-walking group had greater reduction in depressive symptoms

Daley et al50

38 Postpartum women (1 year or less) who were at risk of or diagnosed with postpartum depression

Two motivational sessions, including walking and pedometers; 2 support telephone calls (lasted 12 weeks); EPDS assessed depression

Randomized to exercise or usual care

No significant differences between groups on depression (no exercise differences between the groups)

Dritsa et al46

88 Postpartum sedentary women experiencing symptoms of postpartum depression

Exercise intervention for 12 weeks (met with exercise physiologist) or control group; questionnaire assessed outcome variables

Randomized to exercise or control group

Exercise intervention arm had less physical fatigue; effect on depressive symptoms not reported

Ersek et al51

2169 Women who had given birth and had participated in a large overall survey

Participants completed survey items examining exercise and mood

Observational Exercise before and during last trimester of pregnancy had a positive effect on “interest” and pleasure but no effect on depressed mood

Heh et al47 80 Postpartum Taiwanese women who had a high risk of postpartum depression

Exercised 3 times a week for 3 months in hospital and at home with exercise CD; EPDS assessed depression

Randomized to exercise or control group

Participants in exercise group had lower depression scores

Ko et al45 61 Postpartum Taiwanese women

Participated in 6 low-intensity exercise sessions in 3 weeks; CES-D assessed depression

Nonrandomized group comparison

No significant differences between groups on depression scores

Koltyn and Schultes44

20 Women who had delivered a baby within the past year

Exercise was one 60-minute bout; STAI assessed anxiety, and POMS assessed depression

Participants randomly assigned to exercise or rest session

Anxiety and depression decreased following exercise and rest sessions; exercise related to less total mood disturbance

Abbreviations: EPDS, Edinburgh Postnatal Depression Scale; CES-D, Center for Epidemiological Studies Depression Scale; STAI, State-Trait Anxiety Inventory; POMS, Profile of Mood State Scale.

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among women experiencing postpartum depressive symptoms.46 Participants who were 4 to 38 weeks postpartum (n = 88) and reported depressive symp-toms were randomly assigned to an exer-cise intervention or control. Participants in the exercise intervention met with an exercise physiologist 4 times over the 12-week intervention. The 90-minute ses-sion included an overview of the benefits of exercise, an exercise prescription, and a supervised exercise session. Participants were also given a heart rate monitor to assess their exercise at home and logged their exercise. A maximal graded exer-cise stress test using a treadmill assessed cardiovascular fitness. Participants in the exercise group reported an aver-age of 124 minutes of exercise per week. Participants in the control group com-pleted exercise questions monthly dur-ing the 12-week intervention phase. The exercise arm reported a significant decrease in physical fatigue relative to the control group at both posttreatment and 3 months following treatment. There were no differences for mental fatigue at posttreatment, but marginal signifi-cant differences between the intervention and group arms (with the intervention arm reporting greater decreases in men-tal fatigue) were observed at the 3-month follow-up. The direct effect of the inter-vention on depressive symptoms was not reported. There are several strengths of this study, including a randomized design and an objective assessment of exercise. One limitation is that the control arm did not control for contact time, so it is pos-sible that the contact received by the intervention arm influenced the findings relative to the control arm.

Heh and colleagues47 examined the effect of exercise on the severity of post-partum depression by randomly assign-ing 80 postpartum Taiwanese women to an exercise or control condition. Only participants who scored 10 or higher on the Edinburgh Postnatal Depression Scale (EPDS) were included in the study. The exercise arm consisted of once a week supervised exercise sessions lasting 1 hour and 2 sessions per week of home-based exercise with a CD. Participants were telephoned once per week to

remind them to complete their home-based exercise sessions. Adherence to exercise was high, in that only 3 women in the exercise arm did not complete the home-based exercise sessions. Both the exercise and control arms were given a 3-page postpartum depression book-let and were asked to log their exercise each day. Results indicated that women in the exercise arm significantly reduced their depressive symptoms score rela-tive to the control group at 5 months. Strengths of this study included the ran-domized design and high adherence to exercise. Limitations included a short-term follow-up, using a non-diagnostic tool to assess depression, and self-report of exer-cise behavior.

Armstrong and Edwards48 examined the effect of a walking program on post-partum depression among postpartum women who scored 12 or more on the EPDS. Participants were randomized to either a 12-week group-based walking program plus social support or a con-trol group. The exercise group reported greater decreases in depressive symp-toms relative to the control group at both 6 and 12 weeks. One major limitation to this study is that it is unclear whether exercise or social support accounts for the effect. Furthermore, the control group did not control for contact time. To address these limitations, the research-ers 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.49 The pram-walking program lasted 12 weeks and consisted of 2 group walk-ing sessions per week lasting 40 min-utes. Participants were also instructed to walk once per week on their own time. The social support control group met once per week for 90 minutes during the 12 weeks. This group met with the other mothers in the study and their chil-dren and did not exercise. Participants in the pram-walking group exhibited improvements in their depressive symp-toms relative to the control group at the end of treatment. Strengths of this study included the random assignment

and control for contact time. Limitations included a small sample size and the fact that depression was not assessed using a structured interview.

Daley and colleagues50 examined the feasibility of an exercise intervention for the treatment of postpartum depression. 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. Participants were randomized to a 12-week exercise condi-tion or usual care. The exercise condition consisted of 2 one-on-one consulting ses-sions focusing on increasing motivation to exercise, coping with barriers, setting goals, increasing self-efficacy, and relapse prevention. The session also included a walking session, and participants were given pedometers. Participants also received 2 support telephone calls. 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 treat-ment phase. Depression was assessed using the Edinburgh Postnatal Depression survey at 12 weeks (ie, posttreatment). Regarding feasibility, the authors were successful in recruiting 38 postpar-tum women; however, response rates were low. Additionally, the authors were unsuccessful in helping the partic-ipants increase their exercise. Therefore, there were no differences in depressive symptoms between the 2 study arms. Limitations of this study included a small sample size and lack of control for con-tact time in the usual care arm.

Another study using an observational design examined the effect of exer-cise before and during the last trimester of pregnancy on depressive symptoms during the postpartum phase.51 The data obtained for the study was taken from the Pregnancy Risk Assessment Monitoring System, which is an annual assessment conducted by the Centers for Disease Control (n = 2169). Physical activity and mood were self-reported within the overall survey, both telephone and survey based. Results indicated that there was no correlation between being physically active before and/or during pregnancy and feelings of depression;

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however, there was a significant correlation between having little interest or plea-sure and reporting physical activity both before pregnancy and during the last tri-mester of pregnancy. A strength of this study was the large sample size; how-ever, a significant limitation was the small number of survey items assessing physi-cal activity and depression.

Finally, Abraham and colleagues52 examined the effect of exercise and eating behaviors during pregnancy on depressive symptoms following child-birth. Participants (n = 181) were women who had given birth during the week prior to the study. They completed a structured interview and a question-naire that retrospectively assessed health behaviors during pregnancy. The EPDS was used to assess depressive symptoms. Participants who reported low-intensity exercise during early pregnancy to con-trol weight and shape were less likely to report postpartum depression fol- lowing birth than women not reporting exercise. Therefore, it appears that exer-cise during pregnancy may have a pro-tective effect on postpartum depression. However, because of a lack of random-ization, definitive causation cannot be inferred regarding the link between exercise and depression.

Limitations

There were several limitations of the pregnancy and postpartum stud-ies included in this review. First, none of the 4 pregnancy studies reviewed were randomized trials (ie, 2 were observa-tional and 2 were nonrandomized group designs). Another limitation is that a majority of the pregnancy studies used the POMS to assess mood. This is prob-lematic, given that the POMS is a current measure of mood and does not assess specific depressive symptoms during the previous 2 weeks. There were signifi-cantly more postpartum studies examin-ing exercise and depression relative to the pregnancy studies. Specifically, 6 of the 9 postpartum studies were randomized tri-als, 2 were observational, and 1 was a nonrandomized group design. One lim-itation of the postpartum studies is that

many of the studies used the Edinburgh Depression Inventory to assess depres-sion, which is a limitation, given that a structured interview is preferred for proper assessment.

Summary and Conclusions

In summary, research indicates that exer-cise might be beneficial for improving mood and anxiety during pregnancy and the postpartum phase. Regarding the preg-nancy studies, 3 of the 4 studies did find a relationship between exercise and mood, and the 1 study not finding an effect had a very small sample size (n = 12). The findings did not appear to vary depend-ing on the trimester of pregnancy. Of the 3 studies finding an effect, 1 study did not examine the effect of the trimester,41 another study only included participants in the second and third trimester,40 and a third study found an effect of exercise on mood in the first and second trimes-ter but not in the third trimester.42 The type and duration of exercise also did not appear to alter the findings. Of the 2 studies examining specific types of exercise, 1 study found that a 90-minute aerobic exercise session improved mood.41 Another study found that both an aqua and gym class improved mood as measured by the POMS.40 This study also found that the aqua class exhibited lower scores on the depression subscale of the POMS (lower depression), indicat-ing some preliminary evidence that the aqua class may have been more influen-tial on mood than the gym class. More research is needed to further examine this finding. Not surprisingly, the stud-ies including 20 or more participants found an effect of exercise on mood, and the study including only 12 participants did not find an effect. Taken together, it appears that there may be a relationship between exercise and mood during preg-nancy; however, additional research using large randomized controlled designs are needed.

Regarding the 9 postpartum studies, 5 found an effect of exercise on depres-sion. There did not appear to be a pattern regarding sample size, randomization,

or type of measure affecting efficacy. Several of the studies included walking, whereas others included low-intensity exer-cise such as yoga and low-intensity stretch-ing. The study including low-intensity stretching did not find an effect of exer-cise on depression.45 Other than this 1 study, type of exercise did not appear to have an impact on the effect of exer-cise on depression. The duration of exer-cise ranged from 30 to 60 minutes per session across the studies. The duration of exercise also did not appear to influ-ence the results of the depression scores. Because there were only 9 studies exam-ining the effect of exercise on depression during the postpartum phase, additional research is needed.

Practical Implications

Based on the preliminary evidence indicating that exercise may be impor-tant in the prevention and treatment of depression during pregnancy and post-partum and given that exercise is help-ful for improving overall health, we suggest that practitioners advise their patients to exercise in cases in which exercise is not contraindicated. Practical implications are outlined in more detail below. Obstetricians, certified nurse mid-wives, nurse practitioners, primary care clinicians, and pediatricians are in a unique position to screen for depres-sion during pregnancy and postpar-tum. A majority of women see their health care providers several times dur-ing pregnancy and should be routinely screened for depression during these vis-its. Additionally, postpartum depression can be screened at the 6-week appoint-ment following childbirth and at the new-born’s well-child visits. The PHQ-9 is a short 9-item questionnaire that can be used to assess depression during preg-nancy.53 Specific items include depressed mood, diminished pleasure, sleep dis-turbance, low energy, self-deprecation, appetite changes, psychomotor changes, difficulty concentrating, and suicidal thoughts. Either the PHQ-9 or the EPDS can be used to assess postpartum depres-sion. The EPDS is a 10-item scale spe-cifically designed to assess postpartum

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depression.54 Items assess enjoyment, self-blaming, anxiety, panic feelings, cop-ing skills, happiness, crying, and suicidal thoughts. Patients who score positive for depression should be referred to a mental health professional for further treatment. The limitation of these instruments is that they rely on self-report, whereas a struc-tured clinical interview would be pre-ferred. However, a structured interview is frequently not possible, given its lengthy time commitment. Therefore, self-report measures can be used as a “screening measure” to determine if further evalua-tion is needed. 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.56 Regarding the EPDS, it has good sensitivity (79%) and specificity (85%) when compared with a structured clinical interview.57

The American College of Obstetrics and Gynecologists recommend that pregnant and postpartum women routinely exer-cise, and research indicates that exer-cise might help with depression during pregnancy and the postpartum phase. Therefore, we recommend that health care providers advise their patients to exercise. Health care providers could provide exercise prescriptions to women and discuss the benefits of exercise in regard to mood. Additionally, parent classes, walking groups, and support groups could be provided. It should be noted that in some cases, exercise may be contraindicated. For example, exer-cise during pregnancy should be stopped if any of the following occur: (1) pla-centa previa after 26 weeks of gestation, (2) premature labor, (3) persistent sec-ond or third trimester bleeding, (4) rup-tured membranes, or (5) preeclampsia/pregnancy-induced hypertension.58 More information on the safety of exercise dur-ing pregnancy is available elsewhere.58 It is important to note that exercise alone may not prevent depression, and in these cases, additional psychological services and referrals may be necessary.

Acknowledgment

This project was supported in part through a grant from the National Institute of Mental Health (MH073820). AJLM

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