Physical Activity Interventions for Postpartum Depression

One of the most hazardous occasions for women to indicate depressive symptoms is the period that follows childbirth (Robertson, Celasun & Stewart, 2003). According to http://www.apa.org (2015) the percentage of women that are likely to experience symptoms of postpartum depression ranges between 9% and 16%. According to the same source (http://www.apa.org, 2015) new mothers diagnosed with postpartum depression lose the ability to cope with everyday tasks and infant care and are prone to experience stress and melancholia. Robertson,Celasun & Stewart,(2003) underline the correlation of the postpartum depression symptomatology with symptoms of severe depression such as lack of energy, low mood and loss of the ability to experience pleasure and report the probable presence of suicidal thoughts.

The same researchers also address this complex disorder for new mothers as a severe health issue that affects the immediate family of the women and pinpoint the need to provide efficient solutions to the target population.

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According to the official website NHS.uk(2015) physical activity has been identified as one of the most prevalent options of treatment of mild depression and evidence supports the coping skills physical activity provides to depressive patients.The website also informs that the psychological therapies such as Cognitive Behavioural Therapy and interpersonal therapy, are the first choice of treatment for moderate postnatal depression to women with no psychiatric history.

Robertson, Celasun & Stewart,(2003) associate the lack of evidence on successful physical activity interventions as potential alternative treatment for postpartum depression with the undermining of the disease by patients and health professionals, particularly when there is scientific evidence on the positive impact of physical activity on depressive symptomatology(Nice.org.uk, 2009).

Currie, & Develin, (2002) acknowledge the lack of leisure time due to childcare and financial struggle as potential barriers for mothers with postnatal depression to engage to physical activity programmes. The meta-analyses conducted by Dennis& Dowswell(2013) on postnatal depression revealed that, compared to standard treatment ,when women received interventions with psychological or psychosocial context, they were less inclined to develop symptoms of the condition.

In their meta-analysis, Daley, Jolly, MacArthur(2009) did not attain evidence to support the replacement of traditional treatment of post-natal depression , with exercise interventions that can deliver results as successful as standard treatment.

In a meta analysis (Dally, Jolly, MacArthur,2009)pram –walking group intercessions have been reviewed as easily accessible to women that are diagnosed with postnatal depression and are promoted by well-being practitioners as beneficial.

The findings also indicate that Intervention focused on aerobics have successfully reduced the levels of depression for mothers and it might be profitable for future interventions targeting PND to include a mixture of aerobic and mild exercise.

The first intervention to be discussed is conducted by Armstrong & Edwards(2004), where they designed a 12-week randomised controlled trial for women that have delivered a baby in the past year. The aim of the RCT was to investigate the impact of a physical activity intervention group which involved pram-strolling women with their infants contrasted with the control group that provided social support. Kanotra et al(2007) acknowledge social support as one of the basic needs that arise for women postpartum.The meetings of the social support group were non-organized. In the pre-intervention stage of physical wellness, depression levels and social support were evaluated by quantitative measures. The same measures evaluated the effects after the 12th week when the Intervention was completed. The aim of the Intervention was for the pram-strolling group to indicate a decrease of the symptoms of postnatal depression while enhancing their wellness levels. The enhancement of the social support levels of both groups and the participants’ perspectives of the activities were defined as secondary endpoints. The researchers deduced that pram-strolling groups, integrated with psychological treatment and medication, can provide a cost-effective alternative form of coping with postnatal depression and improving their personal lives, especially when traditional treatment fails to provide efficient results.

Robertson, Cesalun, Stewart (2013) acknowledge the Edinburgh Postnatal Depression Rating Scale (EPDS), a set of 10 question self-rating scale as the most efficient and approximate to medically evaluated measures for depression.

The researchers (Armstrong & Edwards, 2004) supported that there was a correlation among fitness and depression; the improvement of the one had a significant effect on the improvement of the other. The results supported this rationale. The authors also suggested that other factors could influence the amelioration with regards to the depression levels..

The findings of the trial showed that in the first group, the symptoms of depression were diminished as well as the physical condition of the mothers was considerably ameliorated. Furthermore, social support was sustained at the same levels for the two groups. Although one of the hypothesis was confirmed, several weaknesses of the study have been acknowledged by the researchers that can undermine the value of the trial and establish it as not applicable to new mothers with postnatal depression(Armstrong & Edwards,2004).

As it has not been supported by evidence that the Cornish Walking Wheel, which was the measure used for fitness evaluation, can provide an accurate representation of “the maximum volume of oxygen consumption (VO2max)” (Armstrong & Edwards, 2004, pp.6), it is not a reliable measure for fitness evaluation and needs to be examined in future research. Although it is acknowledged that the researchers tried to evaluate the Cornish Walking Wheel in the pilot study they conducted, this evaluation is not sufficient for the fitness measure to be perceived as reliable for fitness evaluation and future research on physical activity interventions of postnatal depression can explore the validity of the measure.

Another weakness of the trial as recognised by Armstong & Edwards(2004) is the choice of Social Support Interviews (SSI) in the Social Support Group. Although the questionnaire has been used in previous research (O’Hara,1995), it was not assessed for this Intervention against other validated measures. The authors recognise that the lack of results on the levels of social support could be attributed to the brief span of the trial and the measurement’s inability to recognise even mild variation of the social support levels provided to the targeted population. In order for Interventions to be reliable measurement-wise, Armstong & Edwards (2004) suggest that the formulation of appropriate measures for each exercise group of postnatal women needs to be established.

Armstrong & Edwards(2004) raise another issue regarding the small sample of the trial (19 participants) which does not allow the results of the interventions to be generalized. Some other traits that confine the generalizability of the findings include the demographic homogeneity of the trial’s participants as well as the correlation of their high educational, socioeconomic background and regional proximity. As a result, the findings of the interventions, although successful to an extent, they are not applicable to different populations. In order to confirm the success of the randomised controlled trial for postnatal depression focused on pram- walking activities, future trials should be designed to target demographic heterogeneity and the recruitment of participants from various ethnical and socioeconomical backgrounds(Armstrong & Edwards,2004).

The second study of choice is a pilot study conducted in the UK. In their pilot study Gillinsky, Hughes & McInnes(2012) executed a randomized controlled trial that consists of two groups with exercise courses and one 10-week body with pram-strolling activities. The pilot study aims to alter the behaviour of exercise and physical wellbeing and research the efficiency of behavioural and motivational intercessions. The application of accelerometers in the MAMMiS trial (Gillinsky, Hughes & McInnes,2012) provides validity to the trial by measuring impartially the levels of physical activity of the participants for a week. The fact that the accelerometer is on for all the wakening hours of their daily schedule is one of the criteria to differentiate this study to more traditional ones on postnatal depression, is ithe fact that it provides flexibility to the daily schedules of new mothers by measuring the physical activity around the clock.

One of the advantages of the study is the design (RCT),due to the nature of randomised controlled trials providing evidence that the results of an intervention are caused by the treatment option via randomization(Ebbp.org,2015) and the 12-week follow-up after the intervention is completed. One of the limitations of this trial is that it is a pilot study and pilot studies are implemented to locate certain weaknesses and modify them in order to design a larger, successful trial. Pilot studies explore the potential of an intercession and their results should not be taken at face value, especially because the sample sizes of a pilot study are always small(Leon, Davis & Kraemer,2011).Furthermore, the efficacy of the study is potentially limited due to the fact that the trial is delivered by only one health-care professional and to a specific population in the Scottish countryside. In order to design successful intercessions of physical activity on PND based on this pilot study, the target population and the researchers involved need to be distinctive(Gillinsky, Hughes & McInnes,2012).

On an analysis focused on the impact of exercise on depressive symptoms Daley, Jolly& McArthur(2009) concluded that physical activity interventions can be successful only as complementary treatments of postnatal depression, as there was no evidence to indicate successful rates when patients replace standard treatment(medication and psychological support) with exercise. Strohle (2008) in his paper reaches the same conclusion by arguing that although exercise has not been assessed on delivering clinically valid findings and as a result it cannot be applied instead of traditional treatment, whose clinical value is established. However, he acknowledges the helpful reaction exercise has on depression and encourages future researchers to investigate the appropriate duration and regularity of physical activity interventions(Strohle,2008). In addition, Robertson, Celasun & Stewart(2003), recognise as unlikely for researchers to develop a single effective treatment option for the whole population of postnatal depression, considering there is a variety of probable factors than can lead to the development of postnatal depression. Nevertheless, they underline the demand for sufficient evidence that can be used as a manual from professionals in primary and secondary care.(Robertson, Celasun & Stewart,2003).

Conclusively, it has been reviewed that studies investigating the efficiency of physical activity on postpartum depression (Daley, Jolly& McArthur, 2009) lack sufficient follow-up findings and are characterised by small samples. These two factors indicate that postnatal depression interventions targeting exercise have not been sufficiently explored and future researchers should concentrate on developing interventions with larger populations and longer span of follow-up effects.After the literature review conducted by the National Institute for Health and Clinical Excellence in England (NICE)(Nice.org.uk,2009) that supports the benefits of exercise on patients that indicate mild depressive symptoms, the next steps of the research community should be the formulation of cost-effective interventions of moderate exercise that can contemplate the treatment of women diagnosed with postpartum depression (Daley, Jolly,McArthur, 2009).

REFERENCES

http://www.apa.org,.(2015). Postpartum Depression Fact Sheet. Retrieved 2 March 2015, from http://www.apa.org/pi/women/programs/depression/postpartum.aspx

Armstrong, K., & Edwards, H. (2004). The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women. International Journal Of Nursing Practice, 10(4), 177-194. doi:10.1111/j.1440-172x.2004.00478.x

Currie, J., & Develin, E. (2002). STROLL YOUR WAY TO WELL-BEING: A SURVEY OF THE PERCEIVED BENEFITS, BARRIERS, COMMUNITY SUPPORT, AND STIGMA ASSOCIATED WITH PRAM WALKING GROUPS DESIGNED FOR NEW MOTHERS, SYDNEY, AUSTRALIA. Health Care For Women International, 23(8), 882-893. doi:10.1080/07399330290112380

Daley, A., Jolly, K., & MacArthur, C. (2009). The effectiveness of exercise in the management of post-natal depression: systematic review and meta-analysis. Family Practice, 26(2), 154-162. doi:10.1093/fampra/cmn101

Dennis CL, Dowswell T. (2013). Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database of Systematic Reviews, 2, Art. No.: CD001134. DOI: 10.1002/14651858.CD001134.pub3

Ebbp.org,. (2015). EBBP. Retrieved 3 March 2015, from http://www.ebbp.org/course_outlines/randomized_controlled_trials/

(EPDS), E., & Depression., P. (2015). Edinburgh Postnatal Depression Scale. Psychology Tools. Retrieved 4 March 2015, from https://psychology-tools.com/epds/

Gilinsky, A., Hughes, A., & McInnes, R. (2012). More Active Mums in Stirling (MAMMiS): a physical activity intervention for postnatal women. Study protocol for a randomized controlled trial. Trials, 13(1), 112. doi:10.1186/1745-6215-13-112

Kanotra, S., D’Angelo, D., Phares, T., Morrow, B., Barfield, W., & Lansky, A. (2007). Challenges Faced by New Mothers in the Early Postpartum Period: An Analysis of Comment Data from the 2000 Pregnancy Risk Assessment Monitoring System (PRAMS) Survey. Matern Child Health J, 11(6), 549-558. doi:10.1007/s10995-007-0206-3

Leon, A., Davis, L., & Kraemer, H. (2011). The role and interpretation of pilot studies in clinical research. Journal Of Psychiatric Research, 45(5), 626-629. doi:10.1016/j.jpsychires.2010.10.008

Nhs.uk,. (2015). Postnatal depression – NHS Choices. Retrieved 2 March 2015, from http://www.nhs.uk/conditions/postnataldepression/pages/introduction.aspx

Nice.org.uk,. (2009). Depression in adults: The treatment and management of depression in adults | treatments-for-mild-to-moderate-depression | Information for the public | NICE. Retrieved 2 March 2015, from http://www.nice.org.uk/guidance/cg90/ifp/chapter/treatments-for-mild-to-moderate-depression

O’hara, M., & Swain, A. (1996). Rates and risk of postpartum depression— a meta-analysis. Int Rev Psychiatry, 8(1), 37-54. doi:10.3109/09540269609037816

Robertson, E., Celasun, N., and Stewart, D.E. (2003). Risk factors for postpartum depression. In Stewart, D.E., Robertson, E., Dennis, C.-L., Grace, S.L., & Wallington, T.(2003). Postpartum depression: Literature review of risk factors and interventions.

Strohle, A. (2008). Physical activity, exercise, depression and anxiety disorders. Journal Of Neural Transmission, 116(6), 777-784. doi:10.1007/s00702-008-0092-x

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