Current Psychiatry Reports (2019) 21:133

https://doi.org/10.1007/s11920-019-1121-1

REPRODUCTIVE PSYCHIATRY AND WOMEN'S HEALTH (CN EPPERSON AND L HANTSOO, SECTION
EDITORS)

Innovations in the Treatment of Perinatal Depression: the Role

of Yoga and Physical Activity Interventions During Pregnancy
and Postpartum
Elizabeth H. Eustis 1 & Samantha Ernst 2 & Kristen Sutton 2 & Cynthia L. Battle 2,3,4

# Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Purpose of Review We review evidence for physical activity and yoga as interventions for depressed pregnant and postpartum
women.
Recent Findings Results from existing trials have generally indicated that physical activity and yoga interventions are acceptable
to women during the perinatal period, and that these interventions can be effective in reducing depression. However, some studies
have not found significant differences between intervention and control conditions. In addition, symptom improvements were not
always maintained.
Summary The available research on physical activity and yoga as interventions for perinatal depression is encouraging with
regard to feasibility, acceptability, patient safety, and preliminary efficacy. These interventions have the ability to reach a large
number of women who may not engage in traditional treatment. Additional high quality, rigorous, randomized controlled trials
are needed. Future research is also needed to examine the optimal dose of these interventions and how to best increase sustained
engagement.

Keywords Perinatal depression . Postpartum depression . Physical activity . Exercise . Yoga

Introduction rates documented among women from low-income and racial/

ethnic minority backgrounds [4–6]. Perinatal depression is asso-
Perinatal depression is a major problem in the United States ciated with significant negative consequences for women and
(U.S.) and globally that affects an estimated 11–17% of women offspring, including difficulties in the mother-infant relationship
during pregnancy or the postpartum period [1–3], with higher [7, 8], and adverse birth outcomes such as low birth weight, pre-
term birth, and intrauterine growth restriction [9].
Although depression screening during pregnancy and the
This article is part of the Topical Collection on Reproductive Psychiatry
and Women’s Health
postpartum period is more common now than in prior years
[10, 11], the majority of women who experience perinatal de-
* Elizabeth H. Eustis pression do not receive mental health care [12–14]. Efficacious
[email protected] antidepressant medications are available for perinatal depression,
yet many women do not view medication as acceptable during
1
Center for Anxiety and Related Disorders, Boston University, 900
pregnancy or while breastfeeding [15, 16]. With regard to psy-
Commonwealth Ave., Boston, MA 02215, USA chotherapy, evidence supports the efficacy of both cogni-
2
Butler Hospital Psychosocial Research, 345 Blackstone Blvd.,
tive behavioral therapy and interpersonal therapy for peri-
Providence, RI 02906, USA natal depression [17]. However, women may experience
3
Department of Psychiatry and Human Behavior, Warren Alpert
barriers to accessing therapy, including time constraints,
Medical School of Brown University, 700 Butler Drive, lack of childcare, and concerns regarding stigma [16, 18].
Providence, RI 02906, USA Given the high prevalence of perinatal depression, low treat-
4
Center for Women’s Behavioral Health, Women & Infants Hospital ment rates, and significant adverse consequences, there is a
of Rhode Island, 2 Dudley St., Providence, RI 02905, USA pressing need to identify additional treatment options.
 133 Page 2 of 9 Curr Psychiatry Rep (2019) 21:133

Interest in complementary and alternative therapies, includ- Prenatal PA Interventions With regard to PA interventions
ing mind/body approaches (yoga, physical activity), and other developed to address depression among pregnant women,
practices (herbal treatments, vitamins), has substantively in- Battle and colleagues identified characteristics of PA pro-
creased among patients in the general population [19–21], and grams ideally suited for pregnant women, such as use of a
among perinatal women specifically [22, 23, 24•]. Women low to moderate intensity level and inclusion of safety guide-
with depression may engage in complementary health prac- lines [40•]. The same investigators developed a walking pro-
tices for multiple reasons: a desire for a natural approach, gram meeting these criteria designed to help pregnant women
alignment with personal beliefs, and experiencing challenges make gradual increases in daily walking behavior [41]. The
with traditional treatments [25, 26]. In the U.S., women of intervention involved wearing an activity monitor daily and
reproductive age are the primary consumers of complementa- attending six brief sessions with an interventionist over a 10-
ry and alternative medicine/therapies [27, 28], and one-fifth of week period to receive guidance for increasing activity and
pregnant women report using complementary and alternative support for overcoming barriers. Findings from an open pilot
medicine approaches for pregnancy-related reasons [29]. trial of women with a SCID [42] diagnosis of major or minor
Given that these practices can potentially be available at low depression [41] (N = 18) documented that the intervention was
cost, without requiring delivery by a mental health specialist, acceptable to women and referring providers; significant re-
they may provide a particularly accessible strategy for ad- ductions in depressive symptoms were observed via both self-
dressing women’s symptoms. report (EPDS [30]) and an interviewer-rated measure of de-
We review literature on two complementary health prac- pression symptom severity (QIDS [32]). This intervention is
tices for perinatal depression that have received increased at- currently being examined in a larger-scale RCT
tention in recent years: physical activity (PA) and yoga-based (NCT02474862; clinicaltrials.gov).
interventions. We focus on recent trials examining the efficacy
and/or acceptability of PA or yoga interventions that included Postpartum PA Interventions More published research has
samples of pregnant and postpartum women with clinically examined postpartum interventions rather than those for preg-
significant depressive symptoms. Studies met the following nant women. To date, seven RCTs and one pilot trial have
criteria: (1) included perinatal women (pregnancy through tested PA interventions for postpartum depression.
12 months postpartum), (2) with either elevated symptoms Armstrong and Edwards [43] conducted a pilot RCT that com-
of depression (e.g., met cutoff on a validated self-report or pared a 12-week pram-based walking program with social
interviewer-administered measure of depression such as the support to a TAU control condition in a sample (N = 20) of
EPDS [30], PHQ-9 [31], QIDS [32], or HDRS [33]) or a women with depression (EPDS ≥ 12) during the postpartum
diagnosis of major depressive disorder, and (3) examined ei- period. Participants were asked to walk with the group three
ther a PA or yoga-based intervention. Given that much of the times per week for 30–40 min. Women in the pram-walking
research on PA and yoga interventions for perinatal depression condition reported significantly greater reductions in depres-
is in early stages, we included both randomized controlled sive symptoms compared to the control condition. Given the
trials (RCTs) and relevant open trials. design of the study, the authors were not able to examine the
unique effects of PA or social support. Therefore, Armstrong
and Edwards [44] conducted a second small trial to examine
the specific benefits of the PA component of the intervention,
Physical Activity Interventions as opposed to combined PA and social support. They conduct-
ed a 12-week intervention consisting of group pram-based
In addition to improving physical health and fitness, PA inter- walking twice per week versus a social support intervention
ventions have been found to significantly reduce symptoms of for depressed postpartum women (EPDS ≥ 12; N = 19), with
depression in the general population [34, 35•], with aerobic results indicating that women in the PA condition experienced
exercise yielding comparable effects on depressive symptoms greater reductions in depression compared to those in the so-
as psychotherapy and antidepressant medication for mild to cial support condition.
moderate levels of depression [36]. The American College of Daley and colleagues conducted a pilot, and then larger-
Obstetricians and Gynecologists recommends regular PA for scale RCT, comparing a postpartum PA intervention to usual
healthy perinatal women, suggesting 20–30 min per day of PA care in the United Kingdom (UK). In their pilot RCT, they
of moderate intensity [37, 38]. Given this recommendation, randomized postpartum women (N = 38; diagnosis of depres-
combined with the literature supporting the potential ef- sion or EPDS ≥ 12) to either PA or usual care [45]. The 12-
ficacy of these interventions for improving mood in the week intervention included an initial consultation about exer-
general population, research has begun to explore PA cise that included setting goals (progressing to 30 min of
interventions tailored for women during the perinatal moderate intensity activity 5 days/week), walking (to discuss
period [39, 40•]. exertion and safety concerns), discussion of motivation and
Curr Psychiatry Rep (2019) 21:133 Page 3 of 9 133

barriers, and a second consultation 4 weeks later. At post- predominantly low income. The 12-week exercise interven-
intervention, there was no difference between conditions on tion included an initial face-to-face consultation to enhance
depression scores. However, authors noted that recruitment motivation, followed by a combination of different types of
was challenging and the study may have been underpowered exercise based on participants’ preferences including: group
to detect differences between conditions. The same investiga- pram-walking, facility-based group exercise (with free
tors [46•] later conducted a larger RCT (N = 94) in which they childcare), and home-based exercise. The researchers did not
randomized postpartum women diagnosed with depression to find significant differences in depression between postpartum
usual care or usual care plus PA. The 6-month intervention women diagnosed with depression in the PA versus control
period included two face-to-face exercise consultations and a condition [50]. PA participants reported finding the exercise
goal for participants to engage in 30 min of moderate intensity program helpful; however, there were no differences in de-
exercise three times per week by the end of 3 months, and then pression reductions, as measured by SCID-IV diagnosis, nor
to increase to three to five times per week during the second EPDS, at post-intervention and 3-month follow-up. The au-
half of the intervention. Participants received phone calls to thors note that the sample reported a number of socioeconom-
provide support regarding engagement in regular exercise ic challenges, which may also impact mood, and should be
[47]. Participants in the PA condition reported greater reduc- explored in future studies.
tions in depression at a trend level (p = .05), compared to usual Finally, one innovative pilot open trial (N = 11) examined a
care after controlling for baseline EPDS scores. When control- 12-week home-based treadmill intervention in postpartum
ling for demographic variables the difference was statistically women with depression (EPDS ≥ 10) in Australia [51].
significant (p = .03). At post-treatment, a larger percentage of Participants received a treadmill to use during the study and
participants in the PA condition were considered recovered on access to a study-related smartphone application. Participants
the EPDS versus usual care (46.5% vs. 23.8%, p = .03); how- reported significant reductions in depression from pre- to post-
ever, these differences were not maintained at the 6 month intervention; themes from qualitative data indicated that wom-
follow-up. en found having the treadmill was helpful in navigating com-
Another RCT (N = 80) conducted in Taiwan randomized mon barriers to PA (e.g., lack of childcare). Results were lim-
postpartum women with depressive symptoms (EPDS> 10) ited by small sample size and lack of comparison group.
to either PA (a 45-min stretching group) or usual care [48]. In conclusion, out of the seven available RCTs examining
Across the 3-month intervention period, women in the PA postpartum PA interventions for depressed mothers, three
condition attended one hospital-based group exercise class found significant differences between conditions (all in favor
per week and were asked to practice twice weekly at home. of the PA interventions) [43, 44, 48], two found significant
To encourage home practice, women were given a CD of the differences in favor of PA after controlling for either demo-
exercises and received weekly supportive phone calls. The graphic variables or baseline depression scores [46, 49], and
authors found that postpartum women randomized to the PA two did not find significant differences [45, 50]. In addition,
condition reported lower symptoms of depression at post- one pilot trial found significant reductions in depression from
treatment compared with women in usual care [48]. The au- pre- to post-intervention [51].
thors did not examine the possible impact of social interaction
in the group exercise class on outcome. Da Costa and col- PA Prevention Studies While the focus of the current paper is
leagues [49] randomized women with symptoms of depres- on the treatment of perinatal women with existing depression
sion (N = 88; EPDS ≥ 10) to either a 12-week PA condition or symptoms, we note that some recent research has examined
usual care. The intervention included four meetings with an PA interventions as a means of preventing perinatal depres-
exercise physiologist. At the first meeting participants re- sion. Most of these studies have been conducted with pregnant
ceived an individualized exercise plan based on guidelines women in an attempt to prevent postpartum depression.
for cardiorespiratory fitness (60–120 min/week of aerobic ex- Though results have been mixed [52, 53•, 54], there is some
ercise within target heart rate zone) that incorporated partici- support for the role of PA as a preventative intervention. For
pants’ preferences and contexts (e.g., time constraints). After example, Aguilar-Cordero and colleagues randomized asymp-
controlling for baseline depression, participants in the inter- tomatic pregnant women (N = 140) either to an aquatic exer-
vention condition with higher baseline depression reported cise program consisting of 1 hour of aquatic exercises three
greater reductions in depressive symptoms compared to par- times per week from 20 to 37 weeks gestation, or to a
ticipants in the usual care condition with high baseline depres- control condition [53•]. Women in the exercise condi-
sion scores; this difference was no longer significant by the tion reported significantly lower depressive symptoms
three-month follow-up time point. Another pilot RCT (N = (EPDS) between 4 and 6 weeks postpartum compared
24) conducted in the UK randomized postpartum women di- to women in the control condition, suggesting that this
agnosed with depression to either a PA intervention or control. intervention may be able to prevent symptoms of post-
Participants were recruited from an inner city and were partum depression.
 133 Page 4 of 9 Curr Psychiatry Rep (2019) 21:133

Limitations of Research on PA Interventions include some amount of supervised exercise by a professional

for Perinatal Depression (e.g., exercise physiologists) may yield larger effects [35•].
However, many benefits have been noted of lifestyle PA in-
Despite the promising results with regard to feasibility, accept- terventions, including improving cardiovascular disease out-
ability, and preliminary efficacy, the existing literature on PA comes [55] with the flexibility and lower cost of building in
for perinatal depression has limitations. With regard to effica- activities during the course of one’s day, without need for
cy, the majority of studies indicate PA interventions can sig- scheduled exercise sessions or use of special equipment.
nificantly reduce symptoms of depression. However, with one
exception [44], previous studies have examined physical ac-
tivity interventions compared to usual care or control condi- Yoga
tions (rather than more active comparison conditions), and
some studies did not find significant differences compared to Yoga is an ancient mind-body practice that typically consists
these control conditions (e.g., [45, 50]), or found that gains of three main components: physical postures (asanas), breath
were not maintained at follow-up time points (e.g., [46•, 49]). control (pranayama), and meditation (dhyana). Yoga has been
There is also heterogeneity in the type of PA intervention that examined as an intervention for depression in the general pop-
was examined (e.g., type of exercise, setting- group, home- ulation, and existing research indicates that yoga can be more
based, facility-based, duration) and the length [46•, 48]. PA effective than placebo in treating depression and comparable
intervention programs that are group-based have not consis- in efficacy to aerobic exercise and antidepressant medications;
tently examined or controlled for the effect of the social inter- however, there are methodological limitations in this literature
action on outcomes. Assessment measures also varied, al- [56•, 57]. Given the support for yoga as an intervention for
though most studies utilized either a validated semi- depression in the general population, research has begun to
structured interview (e.g., SCID [42]), well-established self- explore yoga interventions for depression during the perinatal
report measures of depression (e.g., EPDS [30], PHQ-9 [31]), period.
and/or interviewer-rated measures (e.g., QIDS; [32]). The var-
iability in types of intervention programs and assessment Prenatal Yoga Interventions To date, six RCTs and two open
makes it difficult to interpret discrepancies in findings across trials have examined prenatal yoga interventions for depres-
studies. The existing literature includes samples from the U.S., sion. Battle and colleagues [58] conduced an open trial (N =
UK, Australia, and Taiwan, and the majority of samples were 34) to examine a 10-week prenatal yoga intervention for preg-
homogenous with regard to demographic variables, which has nant women (12–26 weeks gestation) with either a minor or
previously been identified as a limitation in the field [44]. major depressive episode. Yoga classes were 75 min in length,
However, several studies examined diverse samples with re- focused on breath, postures, and meditation, and were de-
gard to race, ethnicity, and income (e.g., [46•, 50]). An impor- signed to be consistent with prenatal yoga classes available
tant consideration in PA studies is that for women with socio- in the community. Participants reported significant reductions
economic challenges, one’s income and neighborhood setting in depressive symptoms from pre- to post-intervention, as
may have an impact on the types of physical activity that are measured by both self-report measures and interviewer-rated
accessible (e.g., ability to join a gym, access to a safe setting in measures (QIDS [32] and EPDS [30]). Following the open
which to walk). trial, this intervention was compared with a perinatal health
Despite these limitations, research to date suggests that PA education condition in a small randomized trial (N = 20) for
interventions can be feasible, acceptable and safe, and that depressed pregnant women (QIDS > 7 and < 20; [59•]).
they may be effective in decreasing depressive symptoms dur- Although there were no significant differences in depression
ing the perinatal period. Additional research is needed to ex- between conditions post-intervention, possibly related to a
amine these interventions in larger samples in RCTs compared small sample size, effects and results favored the prenatal yoga
to more active comparison conditions. Future research should condition. This intervention is currently being tested in a full-
also examine how to best promote adherence and provide scale RCT (ClinicalTrials.gov: NCT02738216).
support to women who engage in PA interventions (e.g., meet- In another line of research, Field and colleagues conducted
ing with a professional, in-person visits, phone or technology- four RCTs [60–63] examining prenatal yoga interventions. In
based support, and the frequency of support). Several studies these studies, similar 12-week yoga interventions were exam-
included various types of support including weekly sessions ined; brief 20 min sessions focused on yoga (or yoga+tai chi)
[41], in-person meetings with staff members such as exercise postures, but intentionally did not include a focus on breath
physiologists [49, 50], phone calls for support and motivation nor meditation. In one study, pregnant women (N = 84) with a
[46•, 50], or access to a smartphone application with study- SCID diagnosis of depression were randomized to a yoga,
related content [51]. Of note, research on PA for depression in massage, or treatment as usual (TAU) condition. Brief yoga
the general population has found that interventions that and massage sessions occurred twice a week for 12 weeks.
Curr Psychiatry Rep (2019) 21:133 Page 5 of 9 133

Participants in both the yoga and massage conditions reported report significant within-condition reductions in depres-
significantly greater reductions in depressive symptoms ver- sion [59•, 60, 64]. In addition, the two open trials both
sus TAU [62]. In their next study, Field and colleagues [61] reported significant reductions in depression from pre-
randomized pregnant women with a depression diagnosis to post-intervention [58, 65].
(N = 92) to either a combined yoga/tai chi intervention condi-
tion or a waitlist control. The group yoga/tai chi class was Postpartum Yoga Interventions To date, one RCT has been
20 min, and occurred weekly. Participants in the yoga/tai chi conducted on a yoga intervention with a sample of postpartum
condition reported greater reductions in depressive symptoms women with depression (N = 57; HDRS ≥ 12). Buttner and col-
versus those in the waitlist condition [61]. In a similar study, leagues [66•] randomized postpartum women to an 8-week
Field and colleagues [60] randomized pregnant women with a Vinyasa yoga intervention or to waitlist control. Participants were
depression diagnosis (N = 92) to either a weekly yoga inter- asked to attend 2 1 hour long yoga classes per week over 8 weeks
vention or a social support control. Women in the yoga con- and to practice yoga at home. Participants in both conditions
dition reported reductions in depression, but there were no reported significant reductions in depression from pre-post as-
significant differences between the yoga and the social sup- sessment. However, participants in the yoga condition reported
port conditions [60]. The same group conducted another small significantly greater improvements in depression from pre- to
RCT (N = 24) in pregnant women with depression (SCID) post-intervention. In addition, a larger percentage of women in
randomizing women to either a 12-week twice/ week yoga the yoga condition versus the waitlist condition reported clinical-
condition or a parenting education control [63]. There were ly significant change (78% and 59%, respectively).
significantly greater depression reductions among women in
the yoga condition versus those in the parenting education Yoga Prevention Studies Although yoga has been examined
condition. as potential treatment for perinatal depression, to date there
Davis and colleagues [64] randomized pregnant women have been no published trials of yoga tested as a preventative
(N = 46) with symptoms of depression and/or anxiety (EPDS intervention for perinatal depression.
≥ 9, or ≥ 25 on STAI state subscale, or ≥ 35 on trait subscale of
STAI) to an 8-week yoga intervention or TAU. The interven-
tion consisted of 8 weekly 75-min classes taught by a prenatal Limitations of Research on Yoga
yoga instructor, based on Ashtanga Vinyasa yoga modified for Interventions for Perinatal Depression
pregnancy, and included a series of postures, breath practice,
and cool down. Participants in both conditions reported sig- Despite existing evidence on feasibility, acceptability, and
nificant improvements in depression, with participants in yoga some support for efficacy of yoga to treat perinatal depression,
reporting significantly greater reductions in negative affect most published studies have utilized non-active control con-
versus TAU. However, in terms of evaluating yoga as a treat- ditions, such as TAU. When more active comparison condi-
ment for depression, these results should be interpreted with tions were included (e.g., social support groups, massage, par-
caution as study criteria allowed for the inclusion of partici- enting education class), significant differences were found be-
pants who experienced symptoms of anxiety but not tween yoga and comparison conditions in one study [63], but
depression. not in others [59•, 62]. In addition, some studies (e.g., [64,
Finally, an open trial by Muzik and colleagues with preg- 66•]) did not find significant differences in depression be-
nant women (N = 18) with symptoms of depression (EPDS > tween yoga and control conditions, though some of these trials
9), found significant reductions in depressive symptoms from were not fully powered to detect effects, but rather were de-
pre-post intervention following a 10- week mindfulness yoga signed as feasibility studies.
program [65]. Yoga classes were 90 min in length and oc- There has also been significant heterogeneity in the length
curred weekly. Classes included an active focus on mindful- and content of the various yoga interventions. Many yoga
ness and included reminders to notice physical sensations and interventions included a focus on postures, breath, and medi-
be mindful of the baby. Participants also reported a significant tation, but several focused only on postures. Field and col-
increase in mindfulness, but the authors were not able to sep- leagues note that they had this approach to examine the impact
arately examine the potential impacts of yoga (postures and of physical postures alone, hypothesizing physiological mech-
breath), mindfulness, and social support. anisms of action related to this. However, because this ap-
In conclusion, out of the six available RCTs examin- proach is not consistent with yoga classes available in the
ing prenatal yoga interventions, three found significant community, generalizability may be limited. Additional re-
differences in depression between yoga and control con- search is needed to examine the optimal dose and frequency
ditions (all favoring yoga) [61–63]. The remaining three of yoga practice [67–70].
RCTs did not find significant between-conditions differ- While many samples were non-diverse, several studies
ences on depression, although these three studies did [60–62, 65] included samples that were diverse with regard
 133 Page 6 of 9 Curr Psychiatry Rep (2019) 21:133

to, race, ethnicity, and income, increasing the generalizability Conclusions

of results. Additional research is needed to examine barriers to
engaging in perinatal yoga interventions such as availability of Many pregnant and postpartum women experience perinatal
accessible classes in the community, cost, childcare, and depression, and recent studies suggest that complementary
scheduling. health practices such as yoga and PA represent potentially
Given the existing literature on the feasibility, acceptability, feasible, acceptable, and accessible alternatives to standard
and preliminary efficacy of yoga for perinatal depression, fu- forms of mental health care, or may also represent appealing
ture research should examine yoga interventions in larger adjuncts to standard care. It is important to note that this area
RCTs to examine the efficacy of these interventions versus of research is still in the early stages and additional large-scale
active control conditions. RCTs with active comparison conditions are needed.
Moreover, there is a need to examine how to address barriers
to accessing these interventions, and to determine optimal
means of promoting adherence, including potential use of
Future Directions for Research on PA technology. Future research is also needed to examine the
and Yoga Interventions biological and psychological mechanisms of action of mind-
body interventions, as well as the optimal dose needed to
Secondary Outcomes and Mechanisms In addition to exam- produce an effect. The growing body of literature on these
ining the efficacy in reducing depression symptoms, it interventions is promising as an avenue to increase
will be important to conduct research to determine why evidence-based treatment options for perinatal women with
these interventions may prompt symptom reductions—as depression—particularly those who may not readily engage
well as to examine other, related areas of symptoms and in other standard forms of mental health care.
functioning that could potentially be impacted by these
interventions. Some yoga research to date has examined
outcomes beyond depression—anxiety, quality of life,
and social support, and some PA research has examined
changes in levels of fitness (e.g., heart rate, volume of
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