Education, Faculty of
Curriculum and Pedagogy (EDCP), Department of
DSpace
UBCV
Stephenson, Sheryl L.
Master of Physical Education - MPE
University of British Columbia
Postpartum depression is a phenomenon that has baffled physicians and others involved with the care of childbearing women throughout history. Various theories and explanations of the causes of postpartum depression and suggested treatment have been found in the literature. Since exercise has been shown to be effective in treating and potentially preventing other forms of clinical depression, the purpose of this study was to explore the relationship between regular physical activity during the prenatal period and the incidence of postpartum depression. This study recruited 220 volunteer subjects from maternity wards of two hospitals in the Lower Mainland area. The subjects were requested to give information about their physical activity schedule before pregnancy, during their pregnancy period and after. Subjects were also given a demographic questionnaire, the Perceived Stress Scale and the Norbeck Social Support Scale to complete while in the hospital in the days immediately following childbirth. At six weeks postpartum, the women completed the Edinburgh Postpartum Depression Scale, a scale specifically developed to measure postpartum depression. Using two-way ANOVA's, no relationship was found between regular physical activity and postpartum depression. Since perceived stress and social support had been linked to postpartum depression in the literature, a multiple regression analysis was used to investigate their relationships to the incidence of postpartum depression in the current study. Two profile analyses were used to determine if any relationships existed between demographic characteristics, such as age, income level, occupation, and postpartum depression. Perceived stress was the only variable that was found to be related to postpartum depression. A lack of significance between postpartum depression and the variables chosen in this study (with the exception of perceived stress) may indicate that there is still an unknown factor that makes postpartum depression unique when compared with other depressions. Further research is needed in the potential use of exercise for the treatment of postpartum depression. A clearer understanding of the exercise postpartum depression relationshipis necessary before regular exercise might be used to affect the incidence of postpartum depression. It is also recommended that a more detailed record of physical activity be used to gather information about long term exercise schedule, frequency, duration and intensity of participation in physical activity.
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IS THERE A RELATIONSHIP BETWEEN PRE-NATAL EXERCISE AND POSTPARTUMDEPRESSION.bySHERYL LYNN STEPHENSONB.A., Trinity Western University, 1987A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTERS OF PHYSICAL EDUCATIONinTHE FACULTY OF GRADUATE STUDIESDepartment of Physical EducationWe accept this thesis as conformingTHE UNIVERSITY OF BRITISH COLUMBIAMarch 1993©Sheryl Lynn Stephenson, 1993ABSTRACTPostpartum depression is a phenomenon that has baffledphysicians and others involved with the care of childbearingwomen throughout history. Various theories and explanations ofthe causes of postpartum depression and suggested treatment havebeen found in the literature. Since exercise has been shown tobe effective in treating and potentially preventing other formsof clinical depression, the purpose of this study was to explorethe relationship between regular physical activity during theprenatal period and the incidence of postpartum depression.This study recruited 220 volunteer subjects frommaternity wards of two hospitals in the Lower Mainland area. Thesubjects were requested to give information about their physicalactivity schedule before pregnancy, during their pregnancy periodand after. Subjects were also given a demographic questionnaire,the Perceived Stress Scale and the Norbeck Social Support Scaleto complete while in the hospital in the days immediatelyfollowing childbirth. At six weeks postpartum, the womencompleted the Edinburgh Postpartum Depression Scale, a scalespecifically developed to measure postpartum depression.Using two-way ANOVA's, no relationship was found betweenregular physical activity and postpartum depression. Sinceperceived stress and social support had been linked to postpartumdepression in the literature, a multiple regression analysis wasiiused to investigate their relationships to the incidence ofpostpartum depression in the current study. Two profile analyseswere used to determine if any relationships existed betweendemographic characteristics, such as age, income level,occupation, and postpartum depression. Perceived stress was theonly variable that was found to be related to postpartumdepression.A lack of significance between postpartum depression and thevariables chosen in this study (with the exception of perceivedstress) may indicate that there is still an unknown factor thatmakes postpartum depression unique when compared with otherdepressions. Further research is needed in the potential use ofexercise for the treatment of postpartum depression. A clearerunderstanding of the exercise postpartum depression relationshipis necessary before regular exercise might be used to affect theincidence of postpartum depression. It is also recommended thata more detailed record of physical activity be used to gatherinformation about long term exercise schedule, frequency,duration and intensity of participation in physical activity.iiiTABLE OF CONTENTSABSTRACT^ iiLIST OF TABLES^ ivLIST OF FIGURESACKNOWLEDGEMENTS^ viINTRODUCTION 1LITERATURE REVIEW^ 6THEORETICAL PERSPECTIVES ON EXERCISE AND MENTAL HEALTH^6GENERAL EXERCISE AND MENTAL HEALTH KNOWLEDGE^ 9BEHAVIORAL STUDIES ON EXERCISE AND MENTAL HEALTH 13PHYSIOLOGICAL STUDIES CONCERNING EXERCISE AND MENTAL HEALTH 26POSTPARTUM DEPRESSION THEORIES^ 33DESCRIPTIONS OF POSTPARTUM DEPRESSION^ 36PHYSIOLOGICALLY BASED STUDIES 41RISK FACTORS FOR POSTPARTUM DEPRESSION 43THE INFLUENCE OF POSTPARTUM DEPRESSION ON THE MOTHER^55THE INFLUENCE OF POSTPARTUM DEPRESSION ON THE MOTHER CHILDRELATIONSIP^ 57SUMMARY 61METHODOLOGY 65SUBJECTS^ 65DEFINITION OF TERMS^ 68MEASURES 70RESEARCH PROTOCOL 75PROCEDURE^ 77ANALYSIS 78RESULTS 80INTRODUCTION^ 80RESULTS 81SUMMARY 98DISCUSSION^ 99SUMMARY 110BIBLIOGRAPHY^ 117APPENDIX 128A. Demographic questionnaire^ 128B. Perceived Stress Scale 131ivTABLE OF CONTENTSC. Lifestyle (exercise) questionnaire^ 132D. Norbeck Social Support Scale^ 134E. Edinburgh Depression Scale 140F. Ethical Review Documents 142G. Frequency Scores of items on the Demographic and theitems from the Lifestyle habit questionnaire^146H. The relationship of physical activity and perceivedstress^ 152I. The relationship of physical activity and social support_154J. Loss (measured by the Norbeck Social SupportQuestionnaire) and its relationship to postpartumdepression^ 156vLIST OF TABLESTable1. Cell sizes for exercise and depression groups^2. Means and standard deviations of depression scoresfor exercise groups of collapsed cell sizes^3.^Summary table for exercise and depression two-wayANOVA4. Multiple regression analysis with postpartumdepression as dependent variable and the indices ofperceived stress and social support as independentvariables.^ 875. The test of parallelism for depression profiles^896. The relationship of demographic characteristicswith depression^ 907. Descriptive statistics for the three standardizedscales: Perceived Stress Scale, Norbeck Social SupportScale and the Edinburgh Depression Scale^ 958.^Frequency counts of women involved in physical activity_97H-1.^Frequency of participation in physical activitypre-pregnancy and during pregnancy and mean ratingof Perceived Stress Scores.^ 153I-1.^Frequency of participation in physical activitypre-pregnancy and during pregnancy and mean ratingof Social Support Scores. ^155J-1.^The relationship between loss of an importantrelationship and postpartum depression.^ 157838485viLIST OF FIGURES1. Response rates for measures^ 672. Research Protocol^ 763. Depressed and non-depressed profiles for 5 point scaleitems^ 914. Depressed and non-depressed profiles for 4 point scaleitems 92viiACKNOWLEGEMENTSI would like to take this opportunity to thank the staff ofboth Langley and Surrey Memorial hospitals for their cooperationin conducting this study.My deep gratitude is also extended to my family, especiallyto my husband Tim for his continued support and encouragement andto my son Joshua for his inspiration. Finally, I would like toexpress my appreciation to my committee members, Dr. SharonBleuler, Dr. Walter Boldt, Dr. Sue Crawford and Ms. Alison Rice.viii1INTRODUCTIONPsychological responses to childbirth range from a mild toan extreme transient mood disturbance although not all womenexperience negative feelings. Most commonly, three categories ofpostpartum depression are reported; postpartum blues (mildestform), postpartum depression, and postpartum psychosis (mostsevere form). Postpartum blues occur in the first week followingchildbirth with symptoms peaking on the third to seventh day(Gitlin & Pasnau, 1989). Postpartum psychosis affects one or twowomen per 1000 births with the majority of new mothers showinginitial symptoms before the third week postpartum. Postpartumdepression occurs in the weeks following delivery (Gitlin &Pasnau, 1989) and its severity lies between the extremes ofpostpartum psychosis and postpartum blues. The present study hasinvestigated postpartum depression.There is little agreement in the literature on a definitionof postpartum depression. Postpartum depression has been definedby means of elevated self-report depression scores, by thepresence of selected symptoms of depression and by the need to beadmitted to a psychiatric facility and to receive medicaltreatment. Symptoms that persist beyond a two week period and upto one year postpartum may indicate the presence of postpartumdepression. The symptoms are mercurial; there can be a suddenonset and decline, which makes them confusing and difficult todiagnose (Hamilton, 1989). Most commonly, postpartum depressionis regarded as depression occurring in the first postpartum year2and sharing most if not all characteristics of major, minor orother depressions occurring at other times (Steiner, 1990). Theterm depression is used to refer to a spectrum of phenomena thatare distinguished by duration, severity of symptoms, and extentof psychological impairment (Castell & Blumenthal, 1985).Postpartum depression was first described in the pre-Freudian mid-nineteenth century. At that time, the prevailingetiology implicated organic causes. More recently, postpartumdepression has been clustered with various other psychiatricdisorders occurring during the period following childbirth(Selby, Calhoun, Vogel & King, 1980).All childbearing women undergo endocrine and biochemicalchanges yet some experience postpartum depression and some donot. Postpartum depression is likely caused by a factor orfactors other than the endocrine and biochemical changes thatoccur after childbirth. The social stress theory offers oneexplanation of why postpartum depression occurs (Landy,Montgomery & Walsh, 1989). This theory focuses upon socialsupport and life stresses as important variables in the onset ofpostpartum depression.In many studies that investigated postpartum depression, alack of social support and the incidence of life stress eventsappeared to be the strongest predictors of the onset ofpostpartum depression (Paykel, Emms, Fletcher & Rassaby, 1980;O'Hara, 1986; Mercer & Ferketich, 1988).A lack of consistency in both defining and measuring3postpartum depression is evident. Steiner (1990) reported apostpartum depression incidence of 10% to 28%. Dimitrovsky,Perez-Hershberg and Itskowitz (1983) cited 16.67% to 31.48%, andLandy, Montgomery and Walsh (1989) found that 10% to 20% ofchildbearing women experienced postpartum depression. Previousstudies, including the three cited above, often used generalizeddepression scales (ie. the Zung self-report depression scale andthe Beck Depression Inventory). The variable incidence ofpostpartum depression found in childbearing women is partly areflection of the variety of measurement scales used. TheEdinburgh Depression Scale (Cox, Holden & Sagovsky, 1987) was thefirst scale designed specifically to measure postpartumdepression.Prevention and treatment of postpartum depression isimportant not only because of the impact on the mother but alsobecause of the effect it has on the infant. Landy, Montgomeryand Walsh (1989) indicate that studies have found that a mother'sdepression can also have a negative effect on the earlydevelopment of her infant. For example, Cogill, Caplax,Alexandra, Robson and Kumar (1986) found that children of motherswho had experienced postpartum depression showed either behaviordisturbance at three years or cognitive deficits at four years.The optimal strategy is to prevent postpartum depressionfrom occurring because treatments for postpartum depression areoften only partly successful (Unterman, Posner & Williams, 1990).Exercise has been used to effectively treat general depression4and may even aid in reducing its occurrence (Morgan, 1987).Since exercise has been associated with improvement in generaldepression, it may also be effective in cases of postpartumdepression. Ismail (1987) found a positive association betweenmeasures of physical fitness (V02 max and heart rates) andemotional stability. Evidence suggests that regular physicalactivity of a cardiovascular nature may be at least equal to andpossibly more effective than other intervention modalities suchas meditation and pharmacological means (deVries, 1987).As an alternative to antidepressant medication (used totreat mild, moderate and severe depression), regular physicalactivity has been employed to treat clinically depressed patients(Greist, Klein, Eischens, Faris, Gurman & Morgan, 1979; Greist,1987). Aerobic exercise, a variety of exercises that stimulateheart and lung activity for a time period sufficiently long toproduce beneficial changes in the body (Cooper, K.H., 1970), hasbeen found to reduce neuromuscular tension levels and thereforecreate a more relaxed total body state (deVries, 1987). It isbelieved that the ability to relax leads to optimal mental healthover time (Morgan, 1987) which might then reduce the possibilityof developing depression, or postpartum depression.In a recent preliminary investigation, Stephenson (1991)found some support for the hypothesis that aerobic exercise priorto pregnancy and during pregnancy is associated with a diminishedoccurrence of postpartum blues. Women experiencing postpartumblues have an increased risk of also experiencing postpartum5depression (Cox, Connor & Kendell, 1982). Since exercise duringpregnancy seems to help prevent the occurrence of postpartumblues, it may also help to prevent the occurrence of postpartumdepression. Previous studies have found cardiovascular exerciseduring pregnancy to be physiologically safe for both the fetusand the pregnant woman (Clapp & Dickstein, 1984; Goodlin &Buckly, 1984; Snyder & Carruth 1984; Logering, Gilbert & Longo,1984).The present study combines several interesting researchareas; postpartum depression, pregnancy, exercise, and mentalhealth. Although each area alone has generated considerableresearch interest, no studies have investigated the relationshipsbetween these important topics. As well, there is no integratedtheoretical framework that addresses a combination of the topicsof postpartum depression, pregnancy, exercise and mental health.The basis for the present research therefore, lie in the findingsof individual studies on each of the four topics.The purpose of the present study was: to investigate whetherregular physical activity prior to pregnancy and during pregnancywas associated with a reduced mean score (for the physicalactivity group) of postpartum depression. This study was alsointerested in other associated variables (particularly stress andsocial support) to postpartum depression as well as relationshipsbetween other related factors and physical activity. Inaddition, the present study also generated descriptive data aboutpatterns of exercise that pregnant women follow.6LITERATURE REVIEWThere are two main foci in the literature review: exerciseand mental health; and postpartum depression. Each of thesetopics will be discussed separately. In the exercise and mentalhealth realm, studies are reviewed under four headings: 1.Theoretical perspectives on exercise and mental health; 2.General exercise and mental health knowledge; 3. Behaviorialstudies on exercise and mental health and 4. Physiologicalstudies concerning exercise and mental health.^Six areas arediscussed under postpartum depression: 1. Theories of postpartumdepression; 2. Descriptions of postpartum depression; 3.Postpartum depression-physiological studies; 4. Risk factors forpostpartum depression; 5. The influence of postpartum depressionon the mother and 6. The influence of postpartum depression onthe mother-child relationship.Again it must be noted that no one has integrated the topicsof exercise/mental health and postpartum depression into a theoryor theories that address the combined topics. A gap thereforeexists in the literature and the purpose of this study was toinvestigate the combination of exercise, mental health andpostpartum depression.Theoretical Perspectives On Exercise and Mental HealthIn the literature, many theories attempt to explain why7exercise benefits mental health but no single theory issufficient on its own. A variety of social, physiological andcognitive forces interact to bring about and/or maintain positivemental health.Three theoretical perspectives on exercise and mental healthare outlined by Folkins and Sime (1981). 1. Somatopsychictheory: Humans are involved with physical activity and sportbecause the movement, exertion and performance of the bodyinspires behavior (Folkins & Sime, 1981). 2. Physiologicalviewpoints: follow assumptions that are based on an organismicview of the mind-body relationship. For example, DeVries (1968)found a reduction in resting muscle action potential followingexercise training. This in turn is thought to explain tensionrelief. Another popular current hypothesis is that exerciseindirectly causes the release of enkephalins, which in turnresults in a feeling of euphoria. The effects of morphine aresimilar to those of the newly discovered endorphins of whichenkephalin is a subunit. Morgan, Roberts, Brand and Feinerman(1970) propose the hypothesis that exercise, by increasing theefficiency of the adrenal glands and the autonomic nervoussystem, may improve the body's adaptation to stress. In responseto stress, the adrenal cortex secretes corticosteroids whileamines, epinephrine and norepinephrine are released by theadrenal medulla and the autonomic nervous system. 3.Psychological viewpoints: include a variety of explanationsregarding exercise and mental health. One explanation is that8the improved fitness resulting from exercise provides a sense ofmastery. This sense of mastery is interpreted as improved mentalhealth. Aerobic exercise trains one to have an increasedawareness and sensitivity to internal sensations of one's ownbody (biofeedback training) (Danskin & Crow, 1981). Exercise isalso a distraction from stress provoking thoughts. A cognitivelyoriented model puts biofeedback research into a theory ofadaptation and emotion (Lazarus 1975). This theory of adaptationand emotion proposes that physiological changes associated withfitness training affect the adaptation strategies used to handlestress and emotions. In the same manner, a variety of social andpsychological variables are related to the way in which trainingeffects are cognitively appraised. Finally a self-regulation(coping) process, or training effect, improves adaptation to aperson's changing environment.The theories of exercise and mental health outlined aboveare very diverse. Similarly research findings concerningexercise and mental health are quite varied. For the purposes ofthe present paper, the term exercise denotes any one form ofphysical activity that is undertaken to improve or maintainphysical fitness. Physical fitness can be thought of as a set ofattributes that people have or achieve through exercise training(Castell & Blumenthal, 1985).9General Exercise And Mental Health KnowledgeMost studies concerning exercise and mental health can begrouped into the categories outlined by the American NationalInstitute of Mental Health. Based on previous research, theAmerican National Institute of Mental Health has produced a setof consensus statements (Biddle & Fox, 1989) concerning exerciseand mental health. There is general agreement that in terms ofcurrent knowledge:1. exercise is associated with reduced state anxiety;2. exercise is associated with a decreased level of mild tomoderate depression;3. long-term exercise is usually associated with reductions intraits such as neuroticism and anxiety;4. exercise may be an adjunct to the professional treatment ofsevere depression;5. exercise results in the reduction of various stress indices;6. exercise has beneficial emotional effects across all ages andin both sexes.Hughes (1984) states that well over 1,000 articles have beenpublished in scientific journals on the psychological effect ofexercise. Studies have lacked control groups, have employedsmall numbers of subjects (Hartz, Wallace & Clayton, 1982; Blue,1979 & Doyne, Chambless & Beutler, 1983) and most often have beencorrelational in nature. At the end of their review, Folkins andSime (1981) summarized by saying that investigations concerning10the effects of physical fitness on psychological health arepoorly designed. In the studies reviewed, they found only 15% toqualify as controlled experiments (experiments that had randomlyassigned their subjects and used a control group). In addition,most of these studies used clinical populations. Controlledexperiments (experiments that had randomly assigned theirsubjects and used a control group) that used a "normal"population, generally used children as subjects and only onestudy employed a measure of cardiovascular fitness when assessingexercise.Including all empirical studies done since 1980, Leith andTaylor (1990) found 81 data-based studies directly related to thepsychological benefits of exercise involvement. Most of thesestudies used exercise as an intervention or treatment forpsychological distress (eg. anxiety, depression). In 65 out ofthe 81 (80%) studies reviewed, participation in an exerciseprogram was found to be beneficial for psychological health. Theamount of improvement in psychological health varied depending onthe type of study conducted. Leith and Taylor (1990) divided theresearch into one of three categories: pre-experimental, quasi-experimental and experimental. Exercise benefited psychologicalhealth in 7 out of the 9 (78%) pre-experimental studies, 36 outof 46 quasi-experimental studies (78%), and in 13 out of 26 (50%)experimental studies. Because only 50% of experimental studiesfound exercise beneficial to psychological health, these authorsspeculate that in experimental studies exercise is not found to11be linked to improvements in mental health as often. Therefore,more controlled studies are needed. Leith and Taylor (1990) alsosuggest that cardiovascular fitness level should serve as adependent variable in research examining the relationship betweenexercise and psychological health. They note that studiesconcerning fitness at times fail to report the nature of thephysical activity. Leith and Taylor (1990) found no attempts tocorrelate improvements in particular aspects of psychologicalhealth with a specific physical activity. Leith and Taylorsuggest the need for longitudinal studies to investigate the longterm effects of exercise on psychological health.Plante and Rodin (1990) also examined the literature, since1980, that concerned physical fitness and enhanced psychologicalwell-being. They found four popular topics on psychologicalfunctioning in the studies reviewed: psychological well-being andmood, personality and self-concept, physiological stressresponsivity and cognition. Four studies investigated the shortterm (immediately following exercise) effects of exercise onpsychological well-being and nine studies investigated the longterm effects of exercise on psychological well-being. In total,ten of these 13 studies reported improvements in psychologicalwell-being among exercisers. Six of the nine studies concerningthe long-term effects of exercise used experimental designs withrandom assignment of subjects to experimental and control groups.Of these six studies using random assignment, four concluded thatexercise benefitted the subjects psychologically. Plante and12Rodin (1990) found 16 additional studies that weremethodologically less rigorous than the 13 studies mentionedabove. Twelve of the 16 methodologically less rigorous studiesconcluded that exercise is associated with improved psychologicalwell-being and/or mood.Several themes (anxiety, stress, depression and emotionalhealth) link major studies in the combined areas of exercise andpsychological well-being (Biddle & Fox, 1989). For example,favourable changes in emotional health have been reported byIsmail and Young (1976, 1977). Ismail (1987) reported thathabitual exercisers were less anxious than non-exercisers. Eventhough not all reviewed studies reported exercise as havingantidepressant effects, the majority of subjects subjectivelyreported a sense of "exhilaration" and "feeling better" afterregular cardiovascular physical activity (Ismail 1987). Overall,Ismail (1987) regards exercise as an important factor inmaintaining emotional health as well as in preventing mentaldisorders from occurring. It is likely that regular moderatecardiovascular exercise (minimum of three sessions a week) hasmood elevating properties that can alleviate and possibly reduceclinical depression from occurring (Greist, 1987).Various forms of regular cardiovascular exercise (jogging,cycling, aerobics) have been linked to benefits in mental healthyet no single type of physical activity has been found to havethe greatest benefits (Leith & Taylor, 1990). In spite of a lackof experimental control in many of the studies pertaining to13exercise and mental health, there is overwhelming evidence thatexercise is beneficial to mental health. Specific questionsremain concerning the types of activity necessary forimprovement, what aspects of mental health can be improved andwhether exercise may help to prevent mental health problems fromoccurring. More specifically, the present review will nowaddress the influence of exercise on aspects of mental healththat may have similar causes and symptoms to postpartumdepression.Behaviorial Studies On Exercise And Mental HealthThe positive influence of exercise on the cognitions, moods,depressions and general psychological well-being of normalpopulations gives hope that regular exercise may play a role inhelping to prevent postpartum depression. The effect of exerciseon psychological health may depend on a person's expectations forchange as well as the interaction between stress and exercise(Brown, 1991; Brown & Siegel, 1988). This section examinesstudies that investigated, in a variety of subject populations,the topics of cognitions, moods, depression, generalpsychological well-being, expectations for change and thestress/exercise interaction. Most of the studies exploredexercise as treatment for mental health problems and did not lookat its potential role of prevention of mental health disorders.There are conflicting reports of the effect of regular14exercise on cognition. Ismail (1967) found that an exerciseprogram led to improved academic performance in school-agedchildren. O'Connor (1969) found contrasting results in hisstudy. O'Connor randomly assigned children to either a Kephartmotor skills program or to a regular classroom physical educationprogram (minimal activity). No difference in academicachievement between the two groups was found. This lack ofdifference may be because the motor skills program was notfitness oriented like the exercise program used by Ismail (1967).The effects of exercise on depression are more clearlydemonstrated than the effects of exercise on cognition. In aUniversity sample, lower levels of depression were foundfollowing a 10 week exercise program (Brown, Ramirez & Taub,1978). Before the program 101 of the 561 students wereclassified as clinically depressed. After the 10 week programsignificant decreases in the depression levels were found forboth the depressed and normal subjects who exercised but not forthose who did not exercise. Fitness effects were notdemonstrated in this study. In another study using high schoolstudents, Brown, Ramirez and Taub (1978) found significantdecreases in depression after a 10 week program for joggers,wrestlers and tennis players but not for subjects involved insoftball or for the controls (no exercise). The Zung Self-RatingDepression Scale was used in both of the above studies.Morgan, Roberts, Brand and Feinerman (1970) also used theZung depression scale before and after a 6 week exercise program15involving 101 male professors. The exercise groups participatedin jogging, treadmill work, biking, circuit training andswimming. No significant differences in mood improvements werefound between the control group and the exercise groups. Beforethe 6 week program, 11 of the 101 professors were classified asclinically depressed, these same 11 professors experienced asignificant improvement in mood at the end of the six weekprogram.Unlike Morgan, Roberts, Brand and Feinerman (1970), moreconclusive results linking exercise to increased mental well-being were evidenced in a study involving undergraduatevolunteers (Hayden & Allen, 1984). The undergraduate volunteerswere self-selected into one of three groups: sedentary, activenon-runners and committed runners. Hayden and Allen's (1984)findings indicated that being involved in some sort of aerobicactivity on a consistent basis for a prolonged period was moreimportant to mental well-being than the specific type of exerciseone chooses. The authors also noted that their study did notdetermine any causal relations between increased mental well-being and exercise.Corresponding to Morgan, Roberts, Brand and Feinerman'sstudy (1970) above, Folkins, Lynch and Gardner (1972) foundexercise to only benefit the mental health of those who initiallywere in the poorest mental and physical condition. Folkins etal. (1972) studied 44 male and female students enrolled in ajogging class. Fifty students from an archery or golf class16formed the control group. They found the scores from thedepression scale of the Multiple Affect Adjective Checklist(MAACL) to be significantly higher by the end of the joggingclass for the female students than for the male students. At thesame time no change in the MAACL scores occurred in students fromthe archery or golf classes. As well, significant changes inphysical fitness for both male and female joggers occurred.Since only the female students showed positive changes indepression scores, the authors of this study concluded that thosewho were initially in the poorest physical and emotional healthacquired physical and psychological benefits from exercise.Similarly, in a study by Eickhoff, Thorland and Ansorge(1984), improvements in self-concept were only noticed in thosesubjects who were classified as "low fit" prior to the study.They studied the psychological effects of aerobic dancing onyoung adult women. Thirty-nine women were randomly assigned toeither a 10 week aerobic dance program or to a control group.The counselling form of the Tennessee Self Concept Scale as wellas physical fitness tests (resting heart rate, submaximalexercise test and skinfolds) were administered to the subjects.No changes in self concept were found. The authors of this studynoted that all the women were originally fairly fit which mayhave been the reason why no changes in their self conceptsoccurred. The length of the program may also be a factor in whyno differences were evident.Adding further support to the belief that it is improved17physical fitness rather than just involvement in physicalactivity that is associated with improvements in mental health,betterments in overall psychological well-being, depression andperceived stress were significantly correlated with improvementin aerobic power (Norwell, Martin & Salamon, 1991). Forty-threepost-menopausal women were randomly assigned to one of three 12week programs: bicycling twice a week for 30 minutes at 70-85% ofmaximum heart rate; passive exercise; or a sedentary controlgroup that did no exercise. Physical fitness was measured byoxygen uptake, weight, skinfold and girth measures.Psychological functioning was appraised by the Tennessee Self-Concept Scale, the Mental Health Inventory, the Hopkins SymptomsChecklist, the Perceived Stress Scale and the Current HealthSubscale.Contrary to the above finding, Moses, Steptoe, Mathews andEdwards (1989) suggested that it is the increase in the level ofphysical activity not the improved aerobic fitness that causespsychological changes. Moses et al. (1989) used an inner citypopulation of subjects who had an elevated level of tension andanxiety. The subjects were randomly assigned to 1 of 4conditions: high exercise (walking or jogging for 30 minutes at70-75% maximum heart rate four times per week); moderate exercise(20 minutes of walking or jogging at 60% maximum heart rate fourtimes per week); placebo (strength and flexibility exercise donefor 30 minutes with the heart rate not above 50% and not donecontinually, four times per week); or control (waiting list).18Participants were given all psychological measures (Profile ofMoods States POMS, the Hospital Anxiety and Depression Scale HAD,and the trait scale of the State-Trait Anxiety Inventory STAI)before and after the 10 week training program. In each of thetwo experimental conditions, the subject expectations, attention,group attendance and satisfaction with training were wellmatched. Improvements in aerobic fitness were positively relatedto increasing activity levels in the four groups. Prior to the10 week program, subjects had similar scores on the psychologicalmeasures. Post-training significant group differences were foundon POMS tension-anxiety, mental confusion, depression and onperceived coping assets. A three month follow-up using the sametests was also conducted. The difference between groups wasmaintained on follow-up despite some reduction of the fitnesslevel gained. Positive psychological changes were reported onlyby subjects in the moderate exercise condition (Moses et al.,1989).In a study using first year medical students, both fitnesslevel and exercise behavior were found to be significantlyassociated with depression, anger, stress and overt pattern Abehavior (Buchman, Sallis, Criqui, Michall, Dimsdale et al.,1990). Physical activity was assessed by a five minute step testand the Body Mass Index. Exercise behavior was assessed by awritten questionnaire. The subjects were a homogeneouspopulation and the mean fitness level ranged from "very good" to"excellent".19Not only has physical activity been found to be beneficialfor a variety of aspects of psychological functioning (mood,cognitions, well-being, self-concept, depression, anxiety) butalso for a wide variety of populations. Pre-menopausal women,post-menopausal women, juvenile delinquents, students andclinical patients make up some of the varied populations studiedin the exercise and mental health area.After a 15 week exercise program, mildly obese pre-menopausal women were found to have better ratings of generalwell-being than a control group (Cramer, Nieman & Lee, 1991).Measures were administered at both six and 15 weeks afterstarting to exercise. The subjects also completed personal dailylog books, were weighed hydrostatically, and their residual lungvolume was measured. The exercise program consisted of walking,at 60% of heart rate reserve, for 45 minutes five days a week.At 15 weeks, the exercise group showed improvement on the GeneralWell-being (GWB) scores, particularly the two subscales 'energylevel' and 'freedom from health concern or worry'. State anxietyand the frequency of daily hassles were significantly lower onlyat the six week testing session. No improvement was shown on theProfile of Mood States (POMS) measure.Similar improvements in mental health were found in a studyby Hilyer, Wilson, Dillon, Carol, Jenkins, Spencer et al. (1982),who randomly assigned 60 institutionalized juvenile delinquentsto a 20 week physical fitness program or to a control program.After the 20 week program, the exercise group showed a20significant reduction in state and trait anxiety, depression (asmeasured by the Beck depression inventory), anger, fatigue andconfusion. The state and trait anxiety, depression, (and so on)measures were given to both the exercise group and the controlgroup before and after the 20 week exercise program.Goldwater and Collis (1985) found that physical conditioningled to improvement in psychological health. Their study usedmales from 19-30 years who were randomly assigned to either the"high" (vigorous cardiovascular exercise) exercise group or thecontrol group (activities in which the cardiovascular benefitswere minimized). The volunteers were also given paper and penciltests (104 T/F items made up from the Taylor Manifest AnxietyScale, the Lie Scale and the Welshes R-Scale from the MMPI) and acardiovascular fitness test (UVIC step test) before and after thesix week program. Cardiovascular fitness improvements weresignificantly greater in the high exercise group than in thecontrol group. Although not statistically significant theexperimental group appeared to have lower ratings of anxiety andhigher ratings of subjective well-being than the control group.Many studies, on both normal and clinical populations, havefound positive changes in psychological health to be associatedwith regular physical activity. In addition, findings show thatindividuals who are both physically unfit and have poorpsychological health gain the most from exercise (Castell &Blumenthal, 1985; Roberts, Brand & Feinerman, 1970). Sincemethodological problems still plague researchers, Castell and21Blumenthal (1985) question whether it is exercise training alonethat improves psychological health. Brown and Siegel (1988)propose that it is the interaction of stress and exercise thatplays a role in both our physical and mental health.Three hundred and sixty-four females, grades 7-11 completedthe Life Events Survey and the modified version of theSeriousness of Illness Rating Scale at two different times; time1 and time 2 (Brown & Siegel, 1988). A questionnaire was alsogiven to the subjects to assess their level of physical activity.The responses at time 1 indicated that stress, not exercise, wasrelated to illness scores. The interaction of both exercise andstress improved the prediction of illness. The health ofsubjects who were less physically active was influencednegatively by stress. At time 2, the results were the sameexcept that the stress by exercise interaction did notsignificantly contribute to the prediction of illness. Overallthe study showed that the negative impact of stressful lifeevents on health declined as exercise levels increased. Thisfinding supports the stress buffering hypothesis of exercise(exercise helps to negate the effects of stress).Brown (1991) conducted a stricter test of the stressbuffering hypothesis. He studied the health records ofuniversity students and then administered a bike test as well asthe Physical Activity Questionnaire (PAQ), the Life ExperiencesSurvey (LES) and an Illness checklist. Three scales were alsoused to measure psychological distress: the CES-D, the Rosenburg22Self-esteem Scale and a mood measure. Through a hierarchicalregression analysis, the interaction of exercise/fitness andstressful life events was examined to see if it predictedphysical health status. Brown's results supported the claim thatthe harmful effects of life stress can be cushioned by physicalfitness. High life stress was also found to be related tophysical illness but not in physically fit individuals.Physically fit individuals were also found to be less likelyto develop depressive symptoms in a large community sample.Physical inactivity was found to be associated with depressivesymptoms (Farmer, Locke, Moscicki, Dannenberg, Larson & Radloff,1988). The relationship between depressive symptoms and physicalactivity was investigated in an epidemiologic follow-up study tothe First National Health and Nutrition Examination Survey. Thissurvey was conducted on healthy subjects ranging from 25 to 77years of age (Farmer et al., 1988). The original study wasconducted from 1971-1975 and measured depressive symptoms andphysical activity for 3,059 subjects. The 1982-1984 follow-upstudy had only 1,900 subjects because subjects who had physicalconditions that might limit physical activity were excluded fromthe study. The average length of follow-up was eight years.Subjects involved with recreational types of physical activitywere found to be less likely to be suffering from depressivesymptoms. Twice as many depressive symptoms were evident amongsubjects who did not participate in recreational physicalactivities than in those who were active. This relationship was23not explained by differences in age, education, income,employment status, or chronic conditions. Physically inactivewomen who originally did not have depressive symptoms were foundto have depressive symptoms eight years later. Conversely,physically inactive men, who initially had depressive symptoms,were found to have depressive symptoms eight years later atfollow up.In another of the few studies that employed longer termfollow-ups, Sime (1987) found depression levels to be lowerfollowing vigorous exercise. Sime's investigation was a quasi-experimental study that put 15 moderately depressed subjectsthrough an aerobic exercise program. The lower depression levelwas also maintained (and perhaps lowered) at the 21 month follow-up (Sime, 1987).Contrary to the above finding of lasting beneficial effectsfrom exercise, King, Taylor, Haskell & DeBusk (1989) did not findexercise to be associated with any lasting psychologicalbenefits. Sixty male and 60 female employees were randomlyassigned to a treatment condition, which was a six month homebased exercise program, or to a control group (King et al.,1989). The subjects were given the Beck Depression Inventory(BDI), the Profile of Mood States (POMS), a short form of theTaylor Manifest Anxiety Scale and the Hamilton Rating Scale ofDepression bi-weekly. No significant differences were foundbetween the exercisers and controls on scores that measuredexpectations of change. The bi-weekly measures indicated24significant changes in perception of fitness and satisfactionwith physical shape and weight. There was no difference betweenthe treatment group and the control group on the psychologicalvariables at the end of the six months.As well as studies being done on exercise and generaldepression, studies have been conducted on clinically depressedpatients. Many of these studies have compared exercise withother treatment modalities such as counselling and drugs.In a study by Stern, Gorman and Kaslow (1983) 106 MIpatients participated in a 12 week program. The patients wererandomly assigned to 1 of 3 groups; exercise, counselling,control. Both anxiety and depression were significantly reducedin the exercise group but only depression was reduced in thecounselling group. There was no change in levels of anxiety ordepression in the control group.In place of antidepressant medication (often used to treatmild, moderate and severe depression), regular physical activityhas been used to treat clinically depressed patients. Forexample, Greist, Klein, Eischens, Faris, Gurman and Morgan (1979)found that exercise (walking and jogging) was at least aseffective as psychotherapy in the treatment of mild to moderatedepression. In a second study using the Symptom Checklist-90(NIMH), Greist et al. (1987) found that exercise effectivelytreated subjects with moderate depression. This study foundrunning, 30-45 minutes three times per week for 10 weeks, todecrease the depression level of male and female outpatients.25Comparable results were found in a study using volunteerinpatients at a psychiatric clinic who were randomly assigned toan anaerobic or aerobic treatment group (Martinsen, Hoffart &Solberg, 1989). All subjects (38 men and 61 women) completed theMontgomery and Asberg Depression Rating Scale (MADRS), the BeckDepression Inventory (BDI) and a submaximal bicycle ergometertest both when they entered and finished the program. At the endof the eight week program, both groups showed significantlyreduced depression levels. The only significant difference foundbetween the two groups was the increase of maximal oxygen uptakefound in the aerobic group.In another study by Ransford (1982), 29 depressed patientswere randomly assigned to psychotherapy or to exercise. Those inthe exercise group jogged three times a week with a therapist for45-60 minutes. After 10 weeks of exercising, 6 of 8 patientsoriginally diagnosed as depressed by NIMH Research DiagnosticCriteria were no longer classified as clinically depressed. Bothmethods of therapy (exercise or psychotherapy) were equallyeffective in treating depression (Ransford, 1982).The behaviorial studies reviewed above lend general supportto the hypothesis that exercise and physical fitness influencepsychological health in a positive manner. Some lend themselvesto a physiological type of theory and some to a psychologicaltype of theory. More specifically, exercise has been usedsuccessfully to treat both clinical and general depression. Theinitial fitness level and final improved fitness level have been26shown to be related to the amount of improvement experienced inpsychological well-being. It is unclear whether it isparticipation in physical activity alone or whether fitnessbenefits are needed in order to affect mental health positively.Questions remain concerning how much and what types ofexercise are associated with improvement in psychological health.Some studies show only aerobic exercise to be of psychologicalbenefit and others include anaerobic activities as beingbeneficial. Further investigation is needed in this area. Alook at some of the physiological changes occurring duringexercise may help to explain the beneficial effects of exerciseon mental health.Physiological Studies Concerning Exercise And Mental HealthPhysiological studies concerning exercise and mental healthadd further support to the hypothesis that exercise benefitsmental health. This next section discusses some of the findingsconcerning the physiological effects of exercise that positivelyinfluence mental health. Physiological based studies reviewedbelow suggest that exercise has been found to help delay theonset of Premenstrual Syndrome (PMS) and has reduced climacteric(the most intense) symptoms of PMS. It seems that somephysiological similarities exist between postpartum depressionand PMS although they have never been connected in any way.Physiologically, exercise has been found to reduce the incidence27of hot flushes in post-menopausal women. These studies suggestthat exercise enhances aminergic synaptic transmissions andcauses changes that are similar to those changes caused by otherantidepressants (ie. medications and ECT).Post-menopausal women have been found to benefit fromexercise therapy. Wallace, Louell, Talano, Webb and Hodgson(1982) found that a moderate intensity conditioning programappeared to change the climacteric symptomatology of post-menopausal women as well as delay the onset of menopause in pre-menopausal women. They concluded that the exercise did sothrough mechanisms that increased the serum concentrations ofestradiol. Wilbur, Dan, Hendricks Holm (1990) carried theprevious study further with the hopes that physical activity mayoffer a safe alternative to ERT (estrogen replacement therapy)for treatment of menopausal women. Aerobic fitness andparticipation in leisure activity were found to be associatedwith lower nervous and general health symptoms. Only thevasomotor symptoms were not correlated with leisure activity andaerobic fitness.As well as delaying the onset of menopause and changingclimacteric symptomatology of post-menopausal women, regularphysical activity is also thought to help decrease post-menopausal hot flushes (Hammar, Berg and Lindgren, 1990). Theincidence of post-menopausal hot flushes was thought to decreasedue to the effect of regular physical activity on central opioidactivity. Hammar et al. (1990) found that the number of28postmenopausal physically active women with moderate or severehot flushes was significantly lower than in a control group.They found the total number of hot flushes to be the same in bothgroups but the hot flushes experienced by the controls weresignificantly more severe. Canty (1984) suggested the use ofregular aerobic exercise as treatment for premenstrual depressionand tension. No study has investigated the effect of an aerobicexercise program on symptoms of Premenstrual Syndrome (PMS).Aerobic exercise (exercise that stimulates heart and lungactivity for a time period sufficiently long to producebeneficial changes in the body) also causes a reduction ofneuromuscular tension levels (deVries, 1987). Reducedneuromuscular tension means a more relaxed total body state. Intwo experiments, deVries (1987), found evidence for thetranquillizing effect of exercise on the human body. Thetranquillizing (relaxing) effect of exercise was found to behigher than that of meprobate (a frequently prescribedtranquillizer drug). It is believed that the ability to relaxleads to sustained mental health over time (Morgan, 1987).Sustained mental health suggests a diminished possibility ofdeveloping depression, or postpartum depression.Exercise as an antidepressant may be related to alterationof central amine activity (Ransford, 1982). Neurons secreteamines (chemicals) into spaces between them and transmitinformation to neighboring neurons. Therefore, any changes inthe intensity of aminergic synaptic transmission can influence29nervous system functioning. The amine hypothesis of depressionassociates impaired transmission at certain central aminergicsynapses with depression. The decreased levels of aminemetabolites found in the urine of depressed subjects support theamine hypothesis of depression (Ransford, 1982). The loweredlevels of amine metabolites show that there is a reduced rate ofamine release at central synapses and a hypofunction (reducedrole) of these synapses. Anti-depression medications, ECT(electroconvulsive therapy) and REM (rapid eye movement) sleepdeprivation all enhance the synaptic transmission athypofunctional aminergic synapses. Since the treatmentspreviously listed are all said to enhance aminergic synaptictransmission and help to alleviate depression, they also supportthe amine hypothesis of depression (Ransford, 1982). It ispossible that exercise is an effective treatment for depressionbecause it also enhances aminergic synaptic transmission.Stern and Morgane (1974) stated that both anti-depressantmedication and ECT (Electroconvulsive therapy) do not suppressREM (Rapid Eye Movement) sleep but replace it. They found thatboth antidepressant medications and ECT increase aminergicsynaptic transmission and theorize that REM sleep may do thesame. They found that exercise, like medication and ECT, alsodecreases REM sleep. Because exercise acts the same as ECT andmedication it may also replace REM sleep (Stern & Morgane, 1974).It is likely that if exercise helps to compensate for REM sleepit also enhances aminergic synaptic transmission. Exercise and30antidepressants were found to have similar physiological effects(decrease REM sleep, effect the function of neurotransmitters,alter central amine activity) on the body (Ransford, 1982). Thealteration of central amine activity and other biochemicalfactors are another area that have not been investigated withregards to postpartum depression.Gordon, Spector, Sjoerdsma and Udenfriend (1966) in a studywith rats concluded that the synaptic release of brainnorepinephrine was enhanced by exercise. Bliss and Ailion's(1971) study using mice found a relationship between dopamine andexercise. Significant increases in the levels of HVA(homovanillic acid) were found in active mice (Bliss & Ailion,1971). Ransford (1982) summarizes that synaptic transmission inneurons containing norepinephrine or dopamine are enhanced byexercise.The level of catecholamine metabolites, particularly MHPG(3-methody-4hydroxy-phenylglycol, an important metabolite ofnoradrenaline), has been shown to be a biochemical indicator ofcertain depressive disorders (Sothmann & Ismail, 1984). It issuggested above that exercise acts as an antidepressant thatenhances aminergic synaptic transmission in the central nervoussystem (Ransford, 1982). Sothman and Ismail (1984) administeredthe Minnesota Multiphasic Personality Inventory (MMPI) to 34healthy males. The researchers defined anxiety and depression tobe stable personality characteristics resulting from everydaystress. Urine specimens were obtained from these males at two31different times. One sample was taken after eight hours ofrestful sleep and one was collected during the subjects normaloccupational activities. The study found no significantunivariate relationship between MHPG, and personality or physicalfitness. The correlations between depression, physical fitnessand MHPG, though not statistically significant, were in theexpected direction. Physical fitness and depression wereinversely related (r= -0.31) as well as MHPG and depression (r=-0.28). These findings support the hypothesis that increased CNSnoradrenergic activity from long-term exercise helps to reduceself-reported depression.Since exercise does not alleviate depression all of thetime, questions remain concerning exercise and its effects ondepression. It is also this lack of consistency that makes ithard to narrow to one theory. Ransford (1982) comments that lowlevels of amines may have a negative psychological effect on onlycertain types of people. He also notes that the physiologicaland psychological benefits of exercise may not be generalizableto all types of people. Over time, the improved synaptictransmission resulting from long term exercise may be lost(Ransford, 1982). Longitudinal exercise studies with depressedpatients are needed to show how long physiological benefits ofexercise last. If physical activity has potential to affectpostpartum depression it is not known if the physiologicalbenefits of physical activity would last long enough to affectdepression occurring in the postpartum period.32Physiological benefits of exercise may be more evident inathletes because they have been involved in physical activitymore intensely and longer than most people. For example, bloodendorphin levels were higher after acute bouts of exercise inwell-trained athletes (Fraioli, Moretti & Paolucci, 1980).According to Usdin, Bunney and Kline (1979), clinically depressedpatients become less depressed and anxious when beta-endorphin isgiven intravenously. It is also thought that self-confidence andemotional stability in the normal population may be enhanced byendorphin peptides (Lobstein, Mosbacher & Ismail, 1983).Enhanced self-confidence and emotional stability indicate a lowerlevel of depression. Further, it is known that single episodesof aerobic exercise increase the production, excretion, turnover,or transmission of norepinephrine, serotonin and dopamine whoselevels are known to be low in depressed patients (Farmer, Locke,Moscicki, Dannenberg, Larson & Radloff, 1988). Physiologicalchanges caused by exercise help to reduce the severity ofdepression. It is not known whether exercise can help to reducethe incidence of depression.Studies reviewed up to this point have shown an associationbetween exercise and increased mental health, particularlyexercise and its relationship to lower depression levels. Bothbehaviorial studies and physiological studies have beendiscussed. Exercise has not been linked specifically topostpartum depression. Postpartum depression has been shown tobe a unique depression (Pitt, 1968) that has potential to be33influenced by exercise.Postpartum DepressionThere are three recognized categories of postpartumpsychiatric disorders: postpartum blues, postpartum depressionand postpartum psychoses. This review will focus on postpartumdepression. Postpartum depression is defined here as adepression that occurs in the weeks and months followingchildbirth. In spite of the fact that researchers are stillstruggling over its definition, postpartum depression has beenrecognized since the time of Hippocrates when lactation wasthought to be the origin of problems and it was commonly referredto as "milk fever". Reported incidences of postpartum depressionvary between 3% and 27% although most studies give a figure of10% (Harding, 1989). Postpartum depression is an illness thataffects up to 27% of new mothers. Since postpartum depression isoften disregarded by health professionals, the majority ofaffected mothers and their families are left confused anduntreated.Postpartum Depression Theories Gruen (1990) outlines four basic postpartum depressiontheories: organic, psychodynamic, cognitive and situationalstress. The organic theories consider radical changes in34estrogen and progesterone to be the prevailing factors involved(Hamilton, 1984). Clayton (1986) considered thyroid depletion tobe the cause. Ramsay (1986) also reported that a biologicaldisorder of postpartum thyroiditis disease was evident in up to9% of postpartum women. He said that this disease often beginsafter the routine postpartum examination and therefore getsmissed. Postpartum theyroiditis (an often unrecognized disease)may play a role in causing postpartum depression.In contrast with the above theories, the psychodynamictheory hypothesizes that postpartum depression is results fromunresolved personal issues prior to childbirth that become moretroublesome after childbirth (Hopkins, Marcus & Campbell, 1984).Painful experiences from before childbirth surface again afterchildbirth and become too much for the mother to bear. This paincaused from pre-childbirth experiences is then translated intodepression.Cognitive theories assume that those who experiencepostpartum depression have predisposed personalitycharacteristics that make them susceptible to depression(Hopkins, Marcus & Campbell, 1984). According to cognitivetheories, mothers that had unrealistic expectations of childbirthand parenting would be at risk for developing postpartumdepression.The situational stress theory (Gruen, 1990) speculates thata lack of social support plays an important role in the onset ofpostpartum depression. After childbirth, the mother is35particularly vulnerable and needs social support more than shedid previously. If the social support is not there, she willlikely suffer from postpartum depression.Since many variables, both behaviorial and physiological,may play a role in the onset of postpartum depression, aninteractive theory warrants consideration. Kraus and Redman(1986) proposed a family interaction theory of causation forpostpartum depression. Some of the main assumptions from otherpostpartum depression theories are woven into the interactiontheory. For example; 1. postpartum depression is a uniquedisorder, 2. hormonal and bodily changes occur both during andafter pregnancy and 3. postpartum blues is a natural occurrencefollowing childbirth. Kraus and Redman (1986) propose that theway in which the family of a postpartum woman handles the aboveassumptions determines whether the mother of that family will orwill not experience postpartum depression. They describe indetail the interactions occurring between family members afterthe birth of a child. The authors note the specific kinds ofinteractions between the mother and other family members thatlead to the development of postpartum depression. Kraus andRedman (1986) also suggest a pattern of intervention strategiesto combat the unhealthy interactions. Specific steps are givenoutlining ways to help the mother and family realize that the newemotions from childbirth are normal (Kraus & Redman, 1986).Affonso and Domino (1984) concluded that there is no singletheory that can explain or predict postpartum depression.36Postpartum depression is caused by a combination of factors someof which are yet to be identified. Affonso and Domino list riskfactors that seem to be consistently related to postpartumdepression. Of the 10 factors they list, eight of them have todo with either stressors or social support.Parenthood is a dramatic developmental stage in life. It isa time of transition and emotional upheaval during which theadults involved feel a lack of control. Feelings areintensified. Expectations towards childrearing and conforming tosocial expectations are often idealistic. Most psychologicalpreparation is done for the delivery but not for what comes afterthe delivery. It is a time of loss for the parents, a loss ofcontrol, identity, spontaneity, freedom and sometimes of incomeand employment (Gruen, 1990). For the reasons above, both stressand social support are considered to be important factors inpredicting postpartum depression.Descriptions Of Postpartum DepressionPostpartum depression has been studied less than postpartumpsychoses because the condition (postpartum depression) is rarelyreferred to psychiatrists for treatment. Postpartum depressionstudies have mainly occurred in the last 20 years (Kendell,1985). Studies concerning postpartum depression have used postalquestionnaires, general practice consultations and interviews byinvestigators to identify postpartum depression. As well, the37time of assessment has varied from six weeks to six months afterdelivery. Few studies have used operational criteria to definewhat they meant by postpartum depression. A lack of consistentoperational criteria for identifying postpartum depression aswell as discrepancies concerning the time of diagnosis forpostpartum depression exist. There is also disagreementconcerning the nature of the risk factors for the development ofpostpartum depression (Kendell, 1985).Cooper, Campbell, Day, Kennerly and Bond (1988) examined 483women six weeks prior to delivery and then again at three, sixand 12 months postpartum. The Interview for Recent Life Events,the General Health Questionnaire, the Present State Examinationand the Montgomery and Asberg Depression Rating Scale (MADRS)were used to determine the incidence of postpartum depression.At three months postpartum, a similar incidence rate to that ofthe depression rate for the normal population was found forpostpartum depression (7%). The authors concluded that in the 12months postpartum, no increased risk for non-psychoticpsychiatric disorder (depression) occurs. They also do notsupport the view that distinctive clinical features of non-psychotic disorder (postpartum depression) occur afterchildbirth.As suggested above, some researchers doubt that postpartumdepression is a separate and unique depression (Whiffen, 1991).Symptoms that have been found to be unique to postpartumdepression as well as the large number of studies conducted on38postpartum depression provide evidence that postpartum depressionis distinct from other depressive disorders. Higher incidencesof psychotic symptoms are reported in postpartum depression thannon-postpartum depressions. The existence of symptoms ofdisorientation, emotional liability, perplexity, and confusion(which suggest an organic brain syndrome) are more prominent inpostpartum depressions than in other depressions (Harding, 1989).In his classic postpartum depression study, Pitt (1968),describes the symptoms of postpartum depression as "atypical"(different than the symptoms of other depressions). Higher ratesof major and minor depression (as defined by the ResearchDiagnostic Criteria) have been found to be more common in thepostpartum than at other times. The RDC defines major depressionas i) depressed mood or loss of interest, and ii) at least foursymptom groups, including appetite disturbance, sleepdisturbance, agitation or retardation, loss of interest, fatigue,self-deprecation or guilt, indecisiveness or lack ofconcentration, and suicidal ideation. A RDC diagnosis of Minordepression consists of a mood disturbance and only two of theassociated symptoms identified above. Postpartum depressionseems to dissipate at a faster rate than non-postpartumdepressions (Whiffen, 1991). The above factors all point topostpartum depression being a unique disorder.The pattern of depressive illnesses in women may alsosupport the opinion that postpartum depression is a uniquedisorder. In a study on 2,257 women who bore children in 1970,3999 women were classified as having "new" episodes of psychiatricillnesses in either the two years before or the two years afterthe birth of their children (Kendell, Wainwright, Hailey &Shannon, 1976). The pattern of illnesses was as follows: the newepisode rate of depressive illnesses and functional psychosessharply increased in the three months immediately afterchildbirth while a second more sustained but less dramatic riseoccurred in the 10 to 24 months following delivery. Thisinformation was gathered from the psychological consultationrecords of women who bore children in 1970.Similarly, Kumar and Robson (1984) found that more womensought psychiatric help in the year after delivery than in theyear prior to conception. Three quarters of these women soughthelp before their babies were six months old and half of thewomen continued to seek help for the next three years. Thesecondary rise of depressive illnesses and functional psychoses(said to occur in the 10 to 24 months after delivery) found inthe study by Kendell, Wainwright, Hailey and Shannon (1976) wasnot supported by Kumar and Robson's (1984) study.^More thanhalf of the women with persisting emotional difficulties hadnever needed medical help for emotional problems before. Thisstudy found postpartum depression to occur in 28.6% of the womenstudied.Pitt (1968) conducted a well known survey of National HealthService patients having babies in London Hospital. The patientswere assessed at the beginning of the last trimester and at 6-840weeks following delivery. Random interviews were conducted withpatients according to their MMPI scores. All subjects who haddepressive symptoms since delivery, who had unusual and disablingsymptoms, and who had symptoms lasting for more than two weekswere classified as postpartum depression cases (10.8% of thesample, 33 out of 356 subjects). Of the depressed subjects, 27of the 33 were diagnosed by interview and six by post-natalinquiry. The duration of marriage, presence of social stress,psychological stresses, previous psychological illness, anxietyin pregnancy, parity, time in labour and complications indelivery of depressed women were not significantly different fromcontrol subjects. Complications during pregnancy (18 controls,N=323 and 9 depressives, N=33) and transitory teariness (12controls and 21 depressives) were the only significantdifferences between the controls and the depressives. At the oneyear follow-up, 16 of the 28 depressives who completed thefollow-up (there were 33 depressives originally but only 28 ofthe 33 completed the follow-up) were no longer depressed but 3.9%of the sample showed little if any improvement. As mentionedearlier, Pitt refers to postpartum depression as "atypical"depression. He describes "atypical" depression as a milder formof psychological depression commonly seen in younger women orimmature individuals. The prominence of neurotic symptoms, suchas anxiety, irritability and phobias, overshadowing thedepression and the presence of some features that are opposite tothose of classical depression (ie. worsening at the end rather41than the beginning of the day, early rather than late insomnia),make the depression "atypical" (Pitt, 1968). Pitt's (1968) studysuggests that a large proportion of "atypical" depression in thecommunity must arise after childbirth.From the information given above, postpartum depression canbe considered to be a specific depression occurring afterchildbirth. The next sections are concerned with bothphysiological and behaviorial factors associated with postpartumdepression.Physiologically Based Studies On the organic and psychodynamic sides, physiologicalstudies have revealed that biological and hormonal changesoccurring after childbirth may play a significant role in theonset of postpartum depression or other puerperal depressions(Bearn, Fairhall, Robinson, Lightman & Checkley, 1990; Whalley,Robinson & Fink, 1982). This section reports on specificfindings concerning biological changes occurring afterchildbirth.An altered ESN (estrogen or stimulated neurophysin) responsewas found to coincide with the period of maximum risk forpuerperal psychosis (Hearn, Fairhall, Robinson, Lightman &Checkley, 1990). This study developed a neuroendocrine test thatreflects a central response to activation of estrogen receptorsachieved by measurement of plasma levels of estrogen or42stimulated neurophysin (ESN). This central response occurredafter an estrogen challenge. Hearn, Fairhall, Robinson, Lightmanand Checkley (1990) used six healthy women (controls), sevenpatients with anorexia nervosa, and 12 puerperal women in a doseresponse study. They found a dose-dependent response of ESN tooral ethinyl oestradiol. Compared to the response of normalmenstruating women in the early follicular phase of their cycles,the response to 50 ug (micrograms) ethinyl oestradiol in normalpostpartum women is lower. The ESN response in the women withanorexia nervosa was the same as that in normal women. At fivedays postpartum, women showed an attenuated ESN response despitehaving similar oestradiol levels when compared with the controlgroup. The anorexics, who had lower levels of oestradiol thanboth the control group and the puerperal group on day five,showed a normal response. A trend was also found for post-stimulation ESN levels to be higher on day 28 compared to bothday six and day 12 in postpartum women. The authors speculatedthat the altered puerperal response may have resulted from theacute estrogen withdrawal that occurred following delivery. ThisESN response to estrogen provides a new neuroendocrine measurethat tests the relevance of changes in central estrogen receptorresponsiveness in the pathogenesis of puerperal psychosis.Oxytocin secretion was found to be increased at 3-4 weeksprior to the onset of postpartum "mania" in six women studied(Whalley, Robinson & Fink, 1982). Increased oxytocin secretionwas accompanied by high levels of oxytocin related neurophysin.43Both of these increases occur during pregnancy. Oxytocinaseinterferes with oxytocin assays in late pregnancy plasma and,therefore, is thought to be the most likely culprit of postpartum"mania". Being a relatively non-specific peptidase, oxytocinasemay degrade a number of peptides active in the central nervoussystem besides oxytocin (Whalley et al., 1982). Limited datashowed that rapidly changing amounts of a relatively non-specificplacental peptidase affected the symptoms and signs of postpartum"mania". More research in this area is needed.The studies reviewed previously found an altered ESN(estrogen or stimulated neurophysin) response from exercise.This may have been precipitated by the acute estrogen withdrawaloccurring at delivery. As well, the secretion of oxytocin washigher prior to the onset of postpartum "mania". Because ofthis, it is thought that other peptides affecting the centralnervous system may also drop at this time. The evidence in thisarea is not overwhelming yet an altered ESN response still mayplay a role in explaining the occurrence of postpartumdepression. Further research on physiological changes arisingduring the postpartum period is needed.Risk Factors For Postpartum DepressionMany studies have been conducted concerning other factorsthat may be related to the onset of postpartum depression. Theliterature does not present a clear picture of what factors are44associated with the onset of postpartum depression. Both lowsocial support and high stress seem to be the elements that aremost consistently related to postpartum depression. Thefollowing section will review studies concerning factors that putthe mother at risk for developing postpartum depression.Postpartum depression was not found to be consistentlyrelated to pregnancy complications, obstetric difficulties,social class, age, or parity. Harding (1989) suggested that onlypast psychiatric history is of any predictive value forpostpartum depression. Whiffen (1991) found marital tension, lowlevels of social support and negative life stress occurringduring pregnancy and in the postpartum to be the variables mostconsistently associated with the development of postpartumdepression.Coinciding with the findings above, Paykel, Emms, Fletcherand Rassaby (1980) found both life events and lack of socialsupport to be the main predictors of postpartum depression. TheRaskin Three Area Depression Scale was used to measure postpartumdepression in this study. O'Hara, (1986) found that womenexperiencing postpartum depression reported more stressful lifeevents and less support from their spouses than nondepressedwomen. For O'Hara's study, an adapted version of the Schedulefor Affective Disorders and Schizophrenia was used as thepostpartum depression measure. Mercer and Ferketich (1988) alsoreported high stress and lack of social support as predictors ofdepression during pregnancy.45Several other factors such as weaning (Meltzer & Kumar,1985), severe or no nausea during pregnancy (Unterman, Posner &Williams, 1990), previous psychiatric history (Unterman, Posner &Williams, 1990) and economic problems (Unterman, Posner &Williams, 1990) have been found to be associated with theoccurrence of postpartum depression. Susman and Katz (1988)described four women who developed severe depression within twoweeks after beginning to wean their infants. Unterman, Posnerand Williams (1990) discovered that both postpartum psychosis andpostpartum depression were unrelated to obstetric variables suchas type of delivery and complications during pregnancy. Gotlib,Whiffen, Mount, Milne and Cordy (1989), in looking at demographiccharacteristics such as socioeconomic status, formal education,and parity, found these variables to be unrelated to depressionin the postpartum period. They did find that women who listedtheir occupations as housewives were over represented in thecases of postpartum depression. Many variables seem to play arole in the onset of postpartum depression.Kumar and Robson (1984) also note that there is no clearconsensus and much disagreement about factors that predictpostpartum depression. In their study of 119 first time mothers,measures were given throughout pregnancy, well into thepostpartum period, and at follow-up (4 years later). A childassessment was made at follow-up. In the three months afterchildbirth, 15 of the 19 cases of postpartum depression were newcases of depression. All but one of these new cases reported46their symptoms beginning when their babies were around 4 to 6weeks old. They found neither weaning nor the blues to predictpostpartum depression at three months. RDC (Research DiagnosticCriteria) ratings confirmed previous findings that the post-nataldepressions were usually more severe and persistent than thoseseen in early pregnancy. Two factors were common to both pre-natal and post-natal depressions: marital difficulties andserious doubts about having the child.Kumar and Robson (1984) also found that pre-natal depressionbut not post-natal problems were predicted by high scores on the'neuroticism' and 'psychotisism' scales of the Eysenckpersonality questionnaire. Social class, employment status,domestic or financial problems, chronic illness and individuallife events were not associated with pre-natal or postpartumdepression. Both women who had a history of trying to conceivefor more than two years and older women with uneventfulpregnancies were found to be at higher risk for postpartumdepression. Women who had been separated from their husbands themonth prior to the onset of depression and women who haddifficult relationships with their own mothers were also found tobe at risk for postpartum depression. The only obstetricvariable found to be significantly associated with postpartumdepression was premature birth. Another factor found to besignificantly associated with the onset of depression wasbereavement in mid and/or late pregnancy.The presence of stress as a factor in the onset of47postpartum depression again appears in Dean and Kendell's (1981)study. All women in Edinburgh, within a seven year period, whohad had a psychiatric admission within 90 days of delivery, wereidentified and matched for age, year of admission and ResearchDiagnostic Criteria (RDC), with another non-puerperal psychiatricpatient who had a similar case note diagnosis (Dean & Kendell,1981). A peaking of admissions for postpartum depression wasfound in the first two weeks following delivery. Findings showedthat subjects who had a diagnosis of major depressive disorderwere significantly more deluded, labile and disorientated thannon-postpartum controls with the same diagnosis. Dean andKendell's (1981) study also showed additional stressful lifeevents to be present in 80% (27 out of 33) of postpartum womenwith RDC diagnosis of major depressive disorder, in 75% (9 out of12) of postpartum women with diagnosis of manic disorder orschizoaffective disorder and in 3 of the 5 postpartum women withan unspecified functional psychosis. Reported long termdifficulties were marital disharmony, single status, or poorsocial circumstances.O'Hara, Neunaber and Zekoski (1984) focused on the cognitivevulnerability hypothesis of postpartum depression and also foundthe presence of stress to be a factor in postpartum depression.The cognitive vulnerability hypothesis suggests that the externalcircumstances are more stressful or negative according to the waysome people have learned to perceive, interpret, or evaluateevents or situations. Of the 99 women studied, 9% were found to48have a major or minor depression in their second trimester ofpregnancy and 12% had a major or minor depression in the firstnine weeks postpartum. Two of these 9 women were depressed bothbefore and after childbirth. The cognitive vulnerability modelaccounted for about 50% of the variance in postpartum depressionsymptoms with the main vulnerability factors being depression inpregnancy and dysfunctional self-control attitudes. Throughhierarchical regression different factors were found to beassociated with women who had a diagnosis of depression than withwomen who just suffered from symptoms of depression. The numberof previous depressions and depressions in first degree relativeswere the two most significant vulnerability factors. Depressionduring pregnancy was not at all associated with postpartumdepression. Childcare stressors were significantly associatedwith a diagnosis of postpartum depression. Only stressful lifeevents occurring since childbirth and over a short period of timewere found to be significantly related to a diagnosis ofpostpartum depression (O'Hara et al., 1984).In another study based on the cognitive vulnerability model(Cutrona, 1983), the number of child-related events were found tobe a much better predictor of postpartum depression thancognitions about the causes of these events. At most only 10% ofthe variance in postpartum depression was explained by resultsusing the Attributional Style Questionnaire.Using a matched sample of non-childbearing women, O'Hara,Schlechte, Lewis and Vurner (1991) replicated and extended the49findings of an earlier study (O'Hara, Neunaber & Zekoski, 1984).The model used for this study was that stressful events triggerdepression vulnerability. They also assessed hormonal factors.Hormone assays for serum prolactin, serum progesterone andestradiol were taken. The vulnerability-stress model was foundto account for 40% of the variance in the diagnosis of postpartumdepression. Very little association between postpartumdepression and hormonal variables was found. Only thevulnerability by life stress interaction was significant inaccurately predicting depression.Whiffen (1988) studied 115 women in their third trimester ofpregnancy and in the postpartum period. Using the BeckDepression Inventory (BDI), 16.5% were found to have depression,6.1% a major depression, and 10.4% a minor depression. High lifestress during pregnancy, perception of the infant astemperamentally difficult and optimistic prepartum expectationsabout infants were all factors found to be related to womenexperiencing symptoms of depression but not associated with womenwho were not diagnosed as having depression. Diagnosis ofdepression was predicted only by marital tension/vulnerability.The effect of life events was looked at in another study byDowlatshahi and Paykel (1990) who compared 33 matched puerperalcontrols with 33 women who were admitted to a mother and babyunit within one month postpartum. No differences in Paykel'slife interview schedule scores were found between the two groupsin the three months before pregnancy, during the three trimesters50of pregnancy and in the months after delivery to onset ofpostpartum psychosis. Paykel suggested that whensociodemographic factors are taken into account the effect oflife events disappears. Marks, Wieck, Checkley and Kumar (1991)in a study concerning life events and postpartum psychosis,suggest from their findings that postpartum depression may bepreceded by life events, but that life events do not play animportant role in the etiology of postpartum psychosis.Using the Life Events and Difficulties Schedule (LEDS),Martin, Brown, Goldberg et al. (1989) investigated theassociation of life events with the onset of postpartum illnesssevere enough to warrant admission to a psychiatric hospital.They found that, during the period from delivery to onset ofpostpartum depression, significantly more events occurred in thelives of those with postpartum depression than in the lives ofcontrols. The same study also found that, during pregnancy, amajor event or severe difficulty occurred in the lives of only 9out of 26 subjects who were depressed postpartum. The onlypsychosocial stressors found to be associated with postpartumdepression were a lack of a confiding relationship and markedhousing problems.Conversely, psychosocial stressors were found to beimportant in a study by Watson, Elliott, Rugg and Brough (1984)who studied women throughout their pregnancy and during theirfirst postpartum year. They found depression to occur most oftenduring the first three months postpartum and least often in the51second trimester of pregnancy. Long-standing difficultcircumstances and problematic life-events were thought to play animportant role in the onset of emotional difficulties in 26 ofthe 29 women who had affective disorders. The case histories, ofall but two women who had postpartum depression six weeks afterbirth, provided a plausible psychosocial etiological model forpostpartum depression. Because the case histories providedadequate explanations for postpartum depression with the majorityof women, the authors suggested that a biological explanation forpostpartum depression is applicable to a minority of patients.Unlike the above study, biological explanations forpostpartum depression were contemplated in a study by Cox, Connorand Kendell (1982). On four separate occasions, StandardisedPsychiatric Interviews were conducted on women who attended pre-natal clinics at the Simpson Memorial Maternity Pavilion betweenJanuary 1978 and November 1979 (Cox et al., 1982). The findingthat a deterioration of the marital relationship was associatedwith reduced libido caused Cox et al. (1982) to suggest thatconsiderable family vulnerability was associated with postpartumdepression. Postpartum depression persisted for several monthswith the seven subjects who initially experienced postpartumblues. They described the blues as often incorrectly thought ofas being a fleeting or trivial event and suggested that the bluesmay be a meaningful predictor of women at risk for developingpostpartum depression later on (Cox et al., 1982). This studyalso provided indirect support for the endocrine hypothesis in52that, during the ten days after delivery when the fall inestrogen and progesterone levels is maximal, psychiatric symptomswere also maximal. These psychiatric symptoms were found to beunrelated to social factors, marital status or obstetriccomplications. This study did not find pre-natal anxiety to bepredictive of postpartum depression.Cox, Connor and Kendell (1982), found only the blues to be ameaningful predictor for postpartum depression. In contrast totheir findings; personality traits, genetic factors, previouspsychiatric history, psychosocial stressors of pregnancy andphysiological factors/hormonal changes have all been consideredto be predictors for postpartum depression. Petrick (1984), in acase study, graphically demonstrated how the preceding variablesinteracted with one another to produce postpartum depression.Her subject was a 26 year old who was overconcerned with how shewas viewed by others, had a family history of depression, hadexperienced several psychosocial stressors during pregnancy,experienced anxiety in early pregnancy and elation towards theend, and breastfed her baby. Petrick (1984) suggested givingpatients a checklist in the prenatal period to identify high riskmothers. A caution in using this type of check list would be notto assume that all women interpret psychosocial stressors andvarious difficulties encountered in the same manner. Forexample, some women may find moving to a new location very hardto deal with whereas other women may adjust with little or nodifficulty.53Unlike the above case study, Carothers and Murray (1990)concluded by the use of logistic regression that only theEdinburgh Depression Scale (EPDS) score and to a limited extent,reported psychiatric history, were predictive of postpartumdepression. Contrary to Carothers and Murray's (1990) findings,Hopkins, Marcus and Campbell (1984) reported that the majority ofwomen diagnosed as having postpartum depression have never beforebeen diagnosed with any previous psychiatric disorder. Boyce,Parker, Barnett, Cooney and Smith (1991) found that a previousepisode of depression did not increase the risk of womendeveloping postpartum depression. Similarly, as reviewed above,Kumar and Robson (1984) found that high neuroticism wasassociated with pre-natal depression but not with postpartumdepression.In another attempt to predict postpartum depression, Bellowand Hill (1990) found a recall bias in depressed groups whengiven a mixture of positive and self-esteem threatening (SET)words. Further, they hypothesized that women who were notdepressed but showed the depressive SET recall bias pre-natallyand who also experienced self-esteem threatening life eventswould show an increased level of depression at three monthspostpartum. The 156 women, who by the Beck Depression Inventory(BDI) were not depressed pre-natally, completed a recall taskduring their 28th to 37th week of pregnancy. At three monthspostpartum, they were reassessed using the BDI and a structuredinterview. The study failed to find a significant interaction54between recall bias and depression (Bellew & Hill, 1991).According to Pfost, Stevens and Lum (1990), only depressivesymptoms occurring during the pregnancy period (Cutrona, 1982:Gotlib, Whiffen, Mount, Milne & Cordy, 1989; O'Hara, Nuenaber &Zekoski, 1984; O'Hara, Rehm & Campbell, 1982; Pfost, Lum &Stevens, 1989; Whiffen, 1988) and stress intensified by a lack ofsocial support (Cutrona & Troutman, 1986; Hopkins, Campbell &Marcus, 1987; O'Hara et al., 1984; O'Hara et al, 1982; Whiffen,1988) emerge as being consistently related to postpartumdepression. Pfost, Stevens and Lum (1990) in their study of 69women from Lamaze classes, found the best predictor of postpartumdepression to be pre-natal depressive symptoms. In this studythey used the Beck Depression Inventory, a demographic data sheetand a post-delivery questionnaire. These were filled out duringthe last trimester of pregnancy and three weeks after delivery.They did not find stressors that were specific to delivery andchildcare to predict postpartum depression.The prevalence of postpartum depression and existence ofunique depressive symptoms show postpartum depression to bedistinct from other depressions. As well, the literature hasfound many factors to be predictive of postpartum depression.Marital difficulties, single status, poor social circumstances,serious doubts about having the child, postpartum blues, olderwomen with uneventful pregnancies, difficulties in relationshipswith own mothers, family history of depression, previouspsychiatric history, stressful events occurring since the birth55of their child, stressful life events, lack of a confidingrelationship and housing problems include some of the riskfactors for postpartum depression. Some studies reviewed abovehave found conflicting results. Many of the risk factors forpostpartum depression reported throughout the reviewed studiesfit into one of two general categories; 1. a lack of socialsupport or 2. stress. More studies are needed to explainpostpartum depression.The effect of Postpartum Depression On the MotherPostpartum depression has been said to be a debilitatingillness that is often left unassessed and untreated (Gruen,1990). Pitt (1968) describes postpartum depressed mothers asexperiencing depressive symptoms since delivery that have beenunusual to them and somewhat disabling. These symptoms last formore than two weeks and are described as "atypical" as comparedto regular depression. These "atypical" symptoms are prominentlyneurotic symptoms such as anxiety, irritability and phobias.Constant adaptation for parents, newborn and family isundergone following childbirth. This time consists of emotionalhighs and lows. For some, it is a period of growth and forothers a period of growth arrest or even retardation (Butnarescu,1978). A phenomenological study by Tatano Beck (1992) describesthe essential structure of the lived experience of postpartumdepression. Seven mothers who attended a local postpartum56depression support group comprised the subjects for the study.Eleven clusters of themes were organized from 45 statements thatwere originally extracted from the women's transcripts. The 11clusters of themes make up what Tatano Beck refers to as theessential structure of postpartum depression. The eleven themesare as follows: 1. An unbearable loneliness that was due todiscomfort with others and a belief that no one else understoodwhat they were experiencing enveloped the mothers. 2. A glimmerof hope for the end of their living nightmare was provided bycontemplating death. 3. The mothers' waking hours were consumedwith obsessive thoughts of being a bad mother and questioningwhat was happening to them. 4. The mothers grieved for theirloss, haunted by the fear that any normalcy in their lives wasirretrievable. 5. Loss of all previous interests and goals madelife empty. 6. Pondering harming their infants created asuffocating burden of fear and guilt. 7. Mothers were unable toconcentrate, shrouded in fogginess. 8. Just going through themotions, mothers envisioned themselves as robots stripped of allpositive feelings. 9. A feeling of being on the edge of insanitywas brought on by uncontrollable anxiety attacks. 10. Acceptanceof the loss of control of mothers' emotions was alarming anddifficult. 11. The mothers needed to be mothered themselvesbecause they were besieged with insecurities. From thisphenomenological study, two additional variables, self-hatred andhypochondriasis, are also incorporated in the fundamentalstructure of postpartum depression.57Tatano Beck's phenomenological study helps to make theclinical signs and symptoms of postpartum depression, such asfeelings of inadequacy, anxiety, despair, lack of energy, loss ofinterest in sexual activities and compulsive thoughts, into areal experience with lasting memories and effects on the womenwho suffer and have suffered from postpartum depression. Wheninterviewed for Tatano Beck's study, the length of time sincedelivery for the seven mothers ranged from 3 months to 2 1/2years. Postpartum depression was not experienced for a fleetingmoment but affected their lives for an extended period of time.The Influence Of Postpartum Depression On The Mother ChildRelationshipNot only does postpartum depression have a negative impacton the mother but it also has a negative impact on the infant andcontinues to influence the child later in life. This finalsection looks specifically at studies that have dealt with theimpact of postpartum depression on the relationship between themother and child. Since postpartum depression affects both childand mother, it is especially desirable to prevent or at leastminimize the occurrence of postpartum depression in the future.Lynne's (1991) study found that, at 18 months, infants ofdepressed mothers showed poorer outcome on object-concept tasks,were more likely to have mild behaviorial problems (particularlysleep disturbances), and were more insecurely attached to their58mothers. Even though postpartum depressed mothers had recoveredfrom their depression by three months postpartum, the negativeimpact from depression was still evident when the infants were 18months old.Wrate, Booney, Thomes and Cox (1985) studied two intensitylevels of depression (mild or severe) and no depression and foundthat those in the mildly depressed group perceived their childrenas maladjusted. This study was less conclusive than Lynne's(1991) study and used a standardized interview to assessdisturbance in three year olds whose mothers had been assessedfor depression at 3 to 5 months postpartum.Another study (Whiffen, 1990) used the Beck DepressionInventory (BDI) and the Ames Crying Questionnaire (a measure ofinfant temperamental difficulty), which were completed at anaverage of 45 days postpartum. Two years later, the same motherscompleted the BDI and the Infant Characteristics Questionnaire(ICQ) again. Fathers of these children were also asked tocomplete the ICQ independently. Subjects scoring nine and overon the BDI were classified as being depressed. At 45 dayspostpartum, 17.2% of the sample were considered to be depressed.Two years later, 18.5% of the sample were found to be depressed.Findings showed depression to be associated with negativeperceptions of the child at both time 1 and time 2. Paternalratings of child temperamental difficulty were also correlated (r= .18, p < .05) with maternal depression. Findings also showedthat postpartum depression was significantly correlated with the59objective ratings of the two year old child as temperamentallydifficult and dependent. From the measure at 45 days postpartumto the measure at two years, a remarkable stability was shown indepressed mood scores. Since women who had experiencedpostpartum depression were also more likely to be depressed twoyears later, Whiffen (1990) suggested that women who suffer frompostpartum depression may be more vulnerable to dysphoric moodstates. No cause and effect relationships were established as aresult of this study.Women were assessed for postpartum depression at three, sixand 12 months after delivery. Postpartum depression wasidentified in 60 of the 483 women on at least 1 of the 3postpartum assessments (Cooper, Campbell, Day, Kennerley & Bond,1988). Stein, Gath, Bucher, Bend, Day and Cooper (1991)continued this investigation and studied 49 of the 60 depressedsubjects with their infants 19 months after birth. They alsoused a control group of 49 women who had not experiencedpostpartum depression. Five independent assessments were made ofeach mother and child. At 19 months, 9 of the 49 women who wereoriginally diagnosed with depression using the Present StateExamination (PSE) were still found to be depressed cases asdiagnosed using the PSE. The study's two main findings werethat: 1. A reduced quality of the mother-child interaction 19months after the birth of the child was significantly associatedwith maternal depression during the postnatal year. 2. Thisassociation held for mothers who had recovered from their60depression by 19 months after delivery (although this associationwas less strong).In a three year follow-up study, 91 of 103 mothers, who tookpart in an earlier study on postpartum depression, wereinterviewed again and the Richman's Behaviourial ScreeningQuestionnaire (BSQ) was used to assess their children's behaviour(Wrate, Rooney & Cox, 1985). Increased BSQ scores were found tobe associated with those mothers who had previously experiencedpostpartum depressive symptoms. Increased BSQ scores were alsofound to be associated with mothers who had postpartum depressionafter the birth of their first child, mothers who experiencedpostnatal complications, and mothers who had a higher neuroticismscore. Another surprising finding was that behavior disturbancein children was associated with mothers who had shorter postnataldepressive episodes. Long term postpartum depression (for oneyear or more) had no effect on increased behavior disturbance ofthe child. The overall duration of depressive symptoms wasshorter for postpartum depressive symptom (PS) mothers thanpostpartum depressive illness (PD) mothers. PS mothers also weremore reluctant to continue breastfeeding and were more anxiouslypreoccupied with their baby than PD mothers. The authorsspeculate that only when a depressed mother is excessivelyconcerned about her child or uncertain about her maternal roledoes a depressed mood in the puerperium have an enduring effecton the interaction between mother and child. Wrate et al. (1985)suspect biological factors, not mothering difficulties, to be the61cause of long term postpartum depression.The mother-child relationship was influenced by postpartumdepression. Children (18 months old) of mothers who hadexperienced postpartum depression have done poorly on object-concept tasks, had mild behavior problems and were insecurelyattached to their mothers. Mothers who suffered from postpartumdepression had negative perceptions of their children. More longterm studies are needed to establish what the specificrepercussions of postpartum depression are as well as determiningwhat can be done to prevent it from occurring.SummaryThis literature review addressed two broad topics:postpartum depression and the relationship between exercise andmental health. From the review of these topics, it is suggestedthat a relationship between postpartum depression and exerciseexists although a theory base is lacking.Exercise has been shown to improve mental health.Unfortunately some of the studies done in this area have lackedexperimental quality. As well as needing more choiceexperimental studies, longitudinal studies are needed to show howlong the beneficial effects of exercise last. Some of theaspects of mental health that exercise has been shown to benefitare; psychological well-being and mood, personality and self-concept, physiological responses to stress and cognition. This62review has focused on areas of psychological well-being that havesimilarities with and are possibly related to postpartumdepression.A variety of theoretical perspectives on exercise and mentalhealth were explored but it was from the individual studiesreviewed that the present study derived its purpose. The variousreviewed studies used different theoretical frameworks as a basisfor their studies. As well as differing theoretically, somestudies contradicted findings from other studies. All in all,both physical activity and physical fitness have been found to berelated to improved mental health in a variety of subjectpopulations. More specifically, exercise has been shown to be aneffective treatment for depression (both general depression andclinical depression).^Physical activity also seems to have muchpotential to have lasting beneficial effects on mental health andit is suggested that it may play a role in preventing some mentalhealth problems from occurring.Postpartum depression is a unique depression occurring afterthe birth of a child. Although various theoretical perspectiveshave attempted to explain postpartum depression, no theory candescribe and predict the occurrences of postpartum depressioncompletely. Complicating the matter further, studies have made adistinction between being diagnosed with and experiencingsymptoms of postpartum depression. Contradictions among findingsalso occur in the postpartum depression literature. The mostconsistent predictors of postpartum depression found in the63literature are a lack of social support and high life stress.Postpartum depression has been shown to be a debilitatingillness for the mother as well as having a negative impact on themother-child relationship. It has also been shown to havelasting negative effects on the children of mothers who havesuffered from postpartum depression. Because of the negativeimpact on the mother and her children, much research has focusedon determining predictors of postpartum depression in order toidentify mothers who are at risk for developing postpartumdepression. When mothers at risk for postpartum depression areidentified they can be treated and observed more effectively.The question of whether it is possible to prevent or minimizepostpartum depression has not been addressed in the research. Nostudies have been found that explore a relationship betweenexercise and postpartum depression.The American National Institute of Mental Health produced aset of consensus statements concerning future directions in thefield of exercise and mental health. Some significant questionsposed were:1. What is the role of exercise in primary prevention?2. What is the effect of exercise on the rehabilitation ofpeople with physical and mental disorders?3. What are the mechanisms that mediate the effects of exerciseon stress?4. What are the effects of exercise on the stress reactivity ondifferent groups, such as those differing by age, sex,64socioeconomic status and personality?5. What are the optimal exercise doses required to produceeffective responses to mental stress?6. What is the effect of exercise compared with otherinterventions?7. What are the effects of exercise on the mental health ofchildren?8. What are the mechanisms underlying exercise effects?(Biddle^& Fox, 1989).Questions that might explore the relationship betweenpostpartum depression and exercise can be derived from a numberof the questions posed by the American National Institute ofMental Health (ie. the role of exercise in prevention, optimaldoses of exercise, the effect of exercise compared to otherinterventions and the underlying mechanisms of). Exercise canprevent physical health problems. Can it also preventpsychological health disorders such as depression, specificallypostpartum depression?65METHODOLOGYIntroductionThis study was a retrospective correlational pencil andpaper study. The main purpose was: to investigate whetherregular physical activity prior to pregnancy and during pregnancywas associated with a reduced mean score (for the physicalactivity group) of postpartum depression. This study alsoidentified additional variables that were also associated withlower ratings of postpartum depression on the EdinburghDepression Questionnaire. It was hoped that in identifyingrelated variables, suggestions might be possible to help womenreduce their postpartum depression rating. Selected variablesincluded physical activity, perceived stress, social support anddemographic characteristics. These were all acquiredretrospectively. The postpartum depression measure (EdinburghDepression Questionnaire) was completed at a later time than theother measures.Subjects Two hundred and twenty volunteer female subjects between theages of 20 and 35 were recruited from selected community hospitalmaternity wards in the lower mainland area of British Columbia.Of the 220 subjects initially consenting to be in the study, 104women completed all five questionnaires (see Figure 1). Thequestionnaires were all distributed at the same time and in the66same order to each subject. The numbers of subjects respondingto the questionnaires drops as each questionnaire demands more oftheir time to complete and their interest wanes in completingpaper work. The number of subjects that completed the EDPS andthe number that completed all 5 questionnaires was different.The completion of the final questionnaire (the EDPS) did notensure that the subjects also completed the first four measures.67Figure 1Response rates for measures. ^Consent Form Dem Q PSS^Life H NSSQ EDPS Completion ofall 5questionnaires220^171^168^163^151^116^10468For details concerning the treatment of consenting subjectsas well as the specific procedures and information given to thesubjects (see Appendix F). The subject population consisted ofboth primiparous (first time mothers) and multiparous (having hadchildren before) individuals. Women who had no social support,who were unwed teen mothers and who were separated from theirbabies for 48 hours or more immediately after birth were notincluded in the study because they were deemed to be at extremerisk for postpartum depression. Women who fell into one of theabove categories also are known to have many other social andpsychological problems and negative feelings that are distinctiveto this population. These women are often initially depressedand represent unique populations. Maternity ward hospitalnurses, therefore, screened the women who were at high risk forpostpartum depression and did not give them project descriptionsor consent forms.Definitions of TermsExercise. In this study, exercise constitutes any regularactivity or program that is designed to improve or maintainphysical fitness. This definition of exercise is contained inthe question used to measure physical activity (see Appendix C,The Lifestyle Habit Questionnaire). Exercise is one applicationof physical activity that is undertaken to enhance or sustainphysical fitness. Physical fitness can be thought of as a set of69characteristics that people have or accomplish through exercisetraining (Castell & Blumenthal, 1985). Health related physicalfitness is associated with cardiorespiratory endurance, muscularstrength/endurance, body composition and flexibility.Postpartum Depression. Postpartum depression is a form ofdepression that occurs in the weeks following delivery. Itsseverity lies between the extremes of puerperal psychosis andmaternity blues. For the purpose of this study, it is defined bya score of 10 or higher on the Edinburgh Depression Scale.Perceived Stress. Perceived stress is the degree to whichsituations in one's life are appraised as stressful. Stresstherefore occurs when life situations are appraised asthreatening and when there are insufficient resources availableto cope with the circumstances. A rating of high perceivedstress is defined in the present study as a high score on thePerceived Stress Scale and inversely a low score means lowperceived stress.Social Support. Social Support is defined as interpersonalinteractions that consist of one or more of the following: thedemonstration of positive affect of one person toward another;the approval of behaviors of one person toward another,understandings, or communicated views; the giving of symbolic ortangible assistance to another (Kahn, 1979). This definition ofsocial support has also been used in the development of theNorbeck Social Support Questionnaire. Therefore for the purposesof the present study high social support is a high NSSQ score and70low social support is a low NSSQ score.Measures Five Self-report Questionnaires were used in this study.Demographic Information Ouestionnaire. (Appendix A) TheDemographic Information Questionnaire was designed by theresearcher to gain information about possible predictors ofpostpartum depression. This questionnaire also provided ageneral description of the subject population and informationabout the homogeneity of the subjects. Additional informationwas needed to determine if specific variables besides exercisemight influence the depression level of these women and if thesevariables contributed to the intent or ability to exercise. Manyof the variables examined have been investigated in previousstudies concerning postpartum depression.The last item on the scale was included specifically becauseattitudes towards physical activity have been found to beassociated with the degree of participation in physical activity.Expectations for change from exercise have also been associatedwith actual positive changes incurred from exercise (Brown,1991). Therefore, attitudes towards physical activity weremeasured to see if there was a link between these and the actionof physical activity and in turn to look at its effect onpostpartum depression. The Lifestyle Habit Questionnaire wasgiven to 5 professionals and 5 non-professionals to test for71understanding.Perceived Stress Scale (PSS). (Appendix B) The PSS wasdesigned to measure the degree to which life situations areappraised as stressful. This measure was included because lifestress has been found to be a significant and consistentpredictor of postpartum depression (Paykel, Emms, Fletcher &Rassaby, 1980; O'Hara, 1986). This particular questionnaire waschosen because the PSS has been found to be a better predictor ofdepression than other life-event measures (Cohen, Kamarck &Mermelstein, 1983). Cohen et al. (1983) studied three separatesamples and found the coefficient alpha reliability for the PSSto be .84, .85 and .86. In all three samples, the correlationsof the PSS with physical and depressive symptomatology were allsignificant at p<.001 (Cohen et al., 1983).Some work on postpartum depression has investigatedattributional styles and how the world is perceived by the mother(Cutrona, 1983; O'Hara, Nuenaber & Zekoski, 1984; Whiffen, 1988).This questionnaire does more than record life-events, itevaluates how these events are perceived by the mother.Lifestyle Habit Ouestionnaire. (Appendix C) Exercise wasmeasured by a single question about physical activity. Thisquestion about physical activity was adapted to address fourseparate time periods; the three months prior to pregnancy, thefirst trimester of pregnancy, the second trimester of pregnancyand the third trimester of pregnancy. An adapted version of thequestion was asked (reworded) four times, each time addressing72one of the four time periods. This question was validatedusing 1,004 subjects enrolled in a worksite health promotionprogram (Schecktman, Barzilai, Rost & Fisher, 1991). The meanage of the 1,004 subjects was 36.6 ± 9.5 years with 73.1% of thepopulation being females. The question had a "significant age-adjusted association with body mass index (p < 0.0001 in womenand p < 0.001 in men), HDL cholesterol (p < 0.0001 in women), andoxygen capacity (p < 0.0007 in women and p < 0.002 in men). Oneself-reported question can provide useful information about whois and who is not participating in regular exercise." (Schecktmenet al., 1991, p.771).Additional questions were asked to determine the pattern ofactivity for pregnant subjects and gain insight into reasons forthe pattern. Since the definition of exercise was stated withinthe question measuring physical activity, it is assumed that thesubjects understood what was meant by physical activity whencompleting the questionnaire.Norbeck Social Support Scale (NSSO). (Appendix D) The NSSQwas designed to measure multiple dimensions of social supportbased on Kahn's (1979) definition of social support. Functionalcomponents measured are affect, affirmation, and aid. The modeof social support (Kahn's concept of convoy) is measured by threenetwork properties: number in the network, duration ofrelationships, and frequency of contact with network members.The loss of social support is also addressed by the NSSQ.The NSSQ was selected because social support has been found73to be a significant factor in the occurrence of postpartumdepression (Paykel, Emms, Fletcher & Rassaby, 1980). Maritaltension has also been shown to be related to postpartumdepression (Whiffen, 1988). Social support encompasses more thanjust the marital relationship. Since the NSSQ includesinformation about both general social support and the maritalrelationship, it was selected instead of a marital questionnaire.The Norbeck Social Support Scale was chosen because it hasbeen shown to be reliable, (.90 to .96 for the subscales) andvalid, (.92 to .94) for a clinically depressed population (Byers& Mullis, 1987). This is important because some subjects whocomplete the NSSQ may fall into the clinically depressedcategory. The Norbeck Social Support Scale has also been shownto be reliable (range: .85 to .92 on the functional items) andvalid for a normal population (Norbeck, Lindsey & Carrieri,1981).The Edinburgh Depression Scale. (Appendix E) The EdinburghDepression Scale (EDPS) was selected because it was designedspecifically for use in the postpartum period. Cox, Holden andSagovsky (1987) compared it to the 30-item General HealthQuestionnaire (GHQ) of Goldberg et al. (1970) and the BeckDepression Inventory (BDI) (O'Hara et al., 1983). Only 37 of 89women, originally obtaining a high score on the GHQ, wereconfirmed as psychiatric cases (Nott and Cutts, 1982).Similarly, only 11 of 19 women, whose BDI scores showed them tohave depression, were confirmed to have depression by the74Research Diagnostic Criteria (RDC). Four out of the 23 women,whose BDI scores indicated they did not have depression, werefound to have depression by the RDC (Cox et al., 1987).The Edinburgh Depression Scale was specifically designed toscreen for postpartum depression. It was not intended to be asubstitute for a clinical assessment of postpartum depression.All, but one woman, in Cox, Holden and Sagovsky's (1987) study,were identified by the EDPS and confirmed by the RDC to have adiagnosis of Definite Major Depressive Illness. The EDPS ismeasured using an interval scale with possible scores rangingfrom 0 to 30 (a higher score indicates greater depression). Coxet al. (1987) used an EDPS threshold score of 12/13, meaningthose scoring 12 or higher were classified as having postpartumdepression. One woman who was not identified by her EDPS scoreas having postpartum depression was confirmed by the RDC to havea diagnosis of Probable Major Depressive Illness. Cox et al.(1987) warned that an EDPS score just under the cut-off of 12should not be taken to mean an absence of depression for thatsubject.The EPDS had a sensitivity (the % of genuine casesidentified) of 95% and a specificity (the % of genuine non-casesidentified) of 93% (Harris, Huckle, Thomas, Johns & Fung, 1989).This study also found the scale to be easily understood bychildbearing women and able to be completed in five minutes. TheEdinburgh Depression Scale found 22% of the population studied toscore higher than 12 (the predetermined cut off point for75postpartum depression) (Harris et al., 1989). Harris et al.(1989) concluded that the value of the EDPS can be increased bylowering the predetermined cut off point for postpartumdepression to 10 and over. Using the cut off point of 10 on theEDPS, 10% of the total number of postpartum cases would goundetected. This is a smaller percentage than if thepredetermined cut off point remains at 12. Therefore, thepresent study used a cut off score of 10 and people with scoresof 10 or higher were classified as postpartum depression cases.Research ProtocolFour questionnaires (the Demographic Questionnaire, thePerceived Stress Scale, the Exercise Questionnaire and theNorbeck Social Support Scale) were completed by the subjectswhile they were in the hospital maternity ward in the daysimmediately following childbirth. The Edinburgh DepressionScale, the fifth questionnaire, was completed by the subjects athome six weeks after childbirth (see Figure 2). The time of sixweeks postpartum was an arbitrary choice and was decided uponbecause past studies using the Edinburgh Scale measuredpostpartum depression at the six week mark. depression.76Figure 2 Research Protocol In the hospital maternity ward^Six weeks after childbirthThe Demographic Questionnaire The Edinburgh DepressionThe Perceived Stress Scale^ScaleThe Lifestyle Habit QuestionnaireThe Norbeck Social Support Scale77Hypothesis Women who participated in regular physical activity duringthe pre-pregnancy and pregnancy period will exhibit asignificantly lower mean score of postpartum depression.ProcedureInitial contact with the volunteer subjects was made throughthe nurses in two British Columbia lower mainland hospitals. Inthe days following childbirth, the nurses provided selected newmothers with the description of the project and a consent form.The nurses were requested to screen subjects and to exclude womenwho had a total absence of social support, who were unwed teenmothers, and who were separated from their babies for over 48hours immediately after birth.In the hospitals, the researcher or an assistant collectedthe completed consent forms in person and delivered thequestionnaires to the mothers. At this time, the researcher wasalso able to answer questions that the subjects had.On the consent form, the researcher also obtainedpermission to call the subjects in their sixth week postpartumand encourage completion of the postpartum depression scale.In order to protect subject identity, the questionnaireswere coded. The subjects names appeared only on the consentforms.Volunteer subjects (N=220) received four questionnaires (the78Demographic questionnaire, the Perceived Stress Scale, theLifestyle Habit Questionnaire and the Norbeck Social SupportScale) to complete during their time at the hospital. They werealso given one questionnaire (the Edinburgh Depression Scale) tobe completed at home in their sixth week postpartum (as statedpreviously, six weeks was an arbitrary choice) and then mailed tothe researcher in a stamped self-addressed envelope.Analysis of Results Participation in physical activity and its relationship topostpartum depression was analyzed through 2 X 2 factorialANOVA's. A separate ANOVA was conducted for the pre-pregnancyperiod, the first trimester of pregnancy, the second trimester ofpregnancy and the third trimester of pregnancy. The level ofsignificance used was 0( =.10 (to protect against Type II error).The dependent variable was the depression score and theindependent variables were the classification of physicalactivity (involved in physical activity and not involved inphysical activity) and the clinical classification of depression(those suffering from postpartum depression and those not).Because both stress and social support have been foundthroughout the literature to be significantly associated withpostpartum depression, this study also investigated theirassociation with postpartum depression. To examine whetherhigher levels of perceived stress and lower levels of socialsupport would be significantly associated with a greater79incidence of postpartum depression, a multiple regressionanalysis was used. Depression was the dependent variable andstress and social support were the independent variables in theequation. The level of significance used was 0( =.05.In order to discover other factors that may be significantlyrelated to postpartum depression, this study also measured avariety of demographic characteristics. Two profile analysesthat tested for parallelism and coincidence were used to examinewhether or not demographic characteristics were significantlyassociated with postpartum depression. One profile was conductedon all of the demographic items that were answered on a 5-pointscale and one on all of the demographic items that were answeredon a 4-point scale. Two separate profiles were used because theheight of each profile depends on the number of points in thescales. Any differences on 5 point scales would be greater thandifferences on 4 point scales.Mann-Whitney U Analyses were conducted to detect additionalrelationships between physical activity and social support, andphysical activity and stress. Again, a significance level of 0(=.10 was used here (to protect against type II error). As well,descriptive statistics were used to obtain an overall picture ofthe subject population. The frequencies of scores from the life-style habit questionnaire were also examined to determine thepattern of activity for pregnant women and to look at reasons whythe women either participated in or did not participate inphysical activity.80RESULTSIntroductionThroughout the four and one half months of data collection,a total of 220 women volunteered to be involved in the study. Ofthese initial 220 volunteers, 185 completed a minimum of 1 of the5 questionnaires. The Demographic questionnaire was completed by171 women, the Perceived Stress Scale by 168 women, the LifestyleHabit Questionnaire (physical activity questionnaire) by 163women, the Social Support scale by 151 women, the EdinburghDepression Scale by 116 women and all five questionnaires werecompleted by 104 women volunteers (see Figure 1).The Demographic questionnaire, Perceived Stress Scale,Lifestyle Habit Questionnaire (physical activity questionnaire)and the Norbeck Social Support Scale were completed by thevolunteers while they were in the hospital maternity wards.These completed questionnaires were then either collected by thenurses or placed into a drop off box at the nurses station. TheEdinburgh Depression Scale was completed six weeks later when themothers were at home and were then mailed to the researcher. Thesix week mark was an arbitrary time chosen and they were thenphoned on one occasion only to try to encourage completion of theEDPS.Of the 116 women (this sharp decline in completion rate wasdue to the EDPS measure being completed six weeks later) whocompleted the Edinburgh Depression Scale, thirty two subjects81(27%) were classified as having postpartum depression (EPDS scoreof greater than or equal to 10). The remaining 84 (72%) wereclassified as non-depressed (EPDS score of 0-9). This 27%classification of depression is within the expected range ofpostpartum depression and therefore suggests that response biasdid not occur. The response rate of 52.7% (of those whoconsented to be in the study and actually completed the entirestudy) in the present study is comparable to the response ratefor other studies using pencil and paper measures. For example,in Miller and Friedman's (1988) study, 265 individuals consentedto be in the study but only 118 (44.5%) completed the study.For information on the subject population of the presentstudy see Appendix G. This appendix supplies information aboutthe demographic characteristics of the subjects as well asinformation about their pattern of physical activity and theirreasons for exercising or not exercising.Results The four ANOVA's used data from 104 subjects (the number ofsubjects who completed all five questionnaires). The alpha levelused in this analysis was «.10 (to protect for Type II error).Because the number of subjects who were involved in physicalactivity and the number of subjects who were classified asdepressed and not depressed was uneven, a random drawing out ofsubjects was done in order to even out the cell sizes for the82ANOVA's. Table 1 shows the original number of subjects in eachcategory. As shown in Table 2., the mean (+SD) of depressionscores for those who participated in exercise and were notdepressed are similar to the means (+SD) of those who did notparticipate in exercise and were not depressed. Similarly, themean (+SD) of depression scores for those who participated inexercise and were depressed are similar to the means (+SD) ofthose who did not participate in exercise and were depressed.The F scores in Table 3 (prior to pregnancy F(1, 52) = 1.000,first trimester F(1,44) = .665, second trimester F(1,28)= .940and third trimester F(1,24) = .368) show no apparent associationbetween exercise and depression scores in any of the four timeperiods.83Table 1Cell sizes of exercise and depression groups depressed not depressedprior to pregnancyphysical activity 16 41no physical activity 14 38first trimesterphysical activity 12 36no physical activity 18 43second trimesterphysical activity 8 24no physical activity 22 55third trimesterphysical activity 7 18no physical activity 23 6184Table 2Means and standard deviations of depression scores for exercisegroups of collapsed cell sizesMean^Std. Dev. NPrior to exercisepregnancy not depressed 4.50 2.03 14depressedno exercise13.79 2.97 14not depressed 5.57 2.65 14Firstdepressedexercise14.86 4.82 14trimester not depressed 5.00 2.49 12depressedno exercise12.83 2.59 12not depressed 5.17 2.76 12Seconddepressedexercise13.67 2.74 12trimester not depressed 5.75 2.05 8depressedno exercise13.38 2.67 8not depressed 5.13 2.64 8Thirddepressedexercise12.63 1.85 8trimester not depressed 5.14 1.57 7depressedno exercise13.57 2.30 7not depressed 5.43 2.37 7depressed 12.43 1.90 785Table 3Summary table for exercise and depression two-way ANOVATime period^Source df SS MS F Sig of FPrior to exercise 1 16.07 16.07 1.49 .228pregnancy depression 1 1207.14 1207.14 111.89 .000ex. by dep 1 .00 .00 .00 1.000within cells 52 561.00 10.79First exercise 1 3.00 3.00 .43 .516trimester depression 1 800.33 800.33 114.33 .000ex. by dep 1 1.33 1.33 .19 .665within cells 44 308.00 7.00Second exercise 1 3.78 3.78 .70 .411trimester depression 1 457.53 457.53 84.21 .000ex. by dep 1 .03 .03 .01 .940within cells 28 152.13 5.43Third exercise 1 1.29 1.29 .30 .587trimester depression 1 416.57 416.57 98.02 .000ex. by dep 1 3.57 3.57 .84 .368within cells 24 102.00 4.2586A multiple regression analysis examined whether or nothigher levels of perceived stress and lower levels of socialsupport were associated with a greater incidence of postpartumdepression. This procedure was conducted on 105 valid andcomplete pieces of data pertaining to the social support,perceived stress and depression ratings of subjects. A pairwisedeletion of missing data was used. The variables of stress andsocial support accounted for 24% (r 4 = .2317, F = 14.6, d.f. 2,94,p < .0001) of the variation in postpartum depression scores. Thevariable stress was found to be positively associated withpostpartum depression (see Table 4). Social support was notfound to be significantly associated with postpartum depressionhowever the results were in the expected direction (see Table 4).The relationship of physical activity and stress as well asthe relationship between physical activity and social support wasdetermined through Mann-Whitney U analyses. These results areshown in Appendix H and I. The only significant relationshipfound (0<= .10) was between physical activity during the firsttrimester of pregnancy and perceived stress (see table H-1).87Table 4Multiple regression analysis with postpartum depression as dependent variable and the indices of perceived stress and social support as independent variables Indep Var. B SESocial support -.007554 .004469Perceived stress .277148* .055737R Square .23713*P < 0.000188Two separate profile analyses were conducted on the datafrom 105 volunteers to examine whether or not demographiccharacteristics had a relationship with the incidence ofpostpartum depression. One profile was conducted on all of thedemographic items that were answered on a 5 point scale and oneon all of the demographic items that were answered on a 4 pointscale. The only items from the demographic questionnaire notaddressed by one of the profile analyses were marital status andthe educational level attained (these were measured on 2 and 8point scales respectively).The non-significant F scores F(6) = .896 (for the 5 pointscales) and F(8) = .887 (for the 4 point scales) from the WilksLambda test of significance indicated that both of the profileswere found to be parallel (see Table 5). The finding ofparallelism is a necessary prerequisite to go on to the next stepof profile analyses and test whether the two profiles aredifferent.^The test for coincidence (Table 6) was non-significant F(1,102) = .827 (for the 5 point scales) and F(1,110)= .927 (for the 4 point scales). This indicates that anydifferences that exist between the profiles of the depressedgroup and the profiles of the non-depressed group are merecoincidence. No relationship exists between any of thedemographic characteristics and postpartum depression. For avisual presentation of the two profiles see Figures 3 (5 pointscales) and 4 (4 point scales).89Table 5The test of parallelism for depression profiles Scale^Test Name Value Approx. F DF Error DF Sig of F5 pt.^Wilks^.97763^.36984^6.00^97.00^.896scale4 pt.^Wilks^.96607^.45217^8.00 103.00^.887scale90Table 6The relationship of Demographic characteristics with depression Scale^ SS^DF^MS^F^Sig of F5 pt.^depression^.01^1^.01^.05^.827scale^within cells 15.32^102 .154 pt.^depression^.00^1^.00^.01^.927scale^within cells 11.64^110 .1191Figure 3. Depressed and non-depressed profiles for 5 point scaleitems.length- length of pregnancyoutcome- birthweight of babytype- type of deliverynbcomp- number of complications with birthmcomp- number of complications with momptotal- number of previous pregnanciesweeks- number of previous pregnancies past 20 weeksbirths- number of previous birthschildren- number of living childrenDepressed=^Non-depressed= _______92Figure 4. Depressed and non-depressed profiles for 4 point scaleitems.age- age of motherincome- total family incomeweight- weight gain during pregnancypregcomp- complications during pregnancyseparate- length of separation from baby at birthbeing- rating of how physical activity effects well-beingDepressed=^Non-depressed= ____93In order to compare the data obtained from this study withdata from previous studies, descriptive statistics are shown foreach of the standardized questionnaires (the Perceived StressScale, the Norbeck Social Support Scale and the EdinburghDepression Scale). These data are shown in Table 7. The meanscore for the Perceived Stress Scale is 25.276 with a range of42. The mean depression score is 8.086 which lies only twopoints away from the cut off for classification of postpartumdepression (a score of 10 or higher). The range of depressionscores is 28 (1 to 29). This table also divides the descriptivedata into the subscales of the Norbeck social support scale. Themean for the subscale 'affect' is the highest at 67.486 ascompared to 62.0 for 'affirm' and 59.905 for 'aid'. Thisindicates that 'affect' (which measures expressions of positiveaffect of one person toward another) is generally scored higherthan 'affirm' (which measures the affirmation or endorsement ofanother persons behaviors, perceptions, or expressed views) or'aid' (which measures the giving of symbolic or material aid toanother). The subscale 'aid' is also the lowest scored in otherstudies using the Norbeck scale (Norbeck, Lindsey & Carrieri,1983). The range of 516, in the total social support scores, isvery large with the scores varying from 19 to 535.'Loss', another subscale of the Norbeck social supportscale, gives information about whether a loss of a significantrelationship occurred in the past year. The loss can refer to aloss by moving, job change, divorce or separation, or death. To94determine whether any relationship existed between 'loss' andpostpartum depression a Mann-Whitney U analyses was conducted(see Appendix J). No significant association between 'loss' andpostpartum depression was determined.95Table 7Descriptive statistics for the three standardized scales:Perceived Stress Scale, Norbeck Social Support Scale and theEdinburgh Depression ScaleStand.ScaleMean Standard^KurtosisDeviationSkewness Range Max.P.S.S. 25.276 7.846 -.300 -.013 42.00 46NSSQTotal 188.714 97.864 .973 1.002 516.00 535Affect 67.486 35.169 1.372 183.00 188Affirm 62.000 32.778 .874 1.037 154.00 160Aid 59.905 32.365 1.458 1.068 182.00 190EDPS 8.086 4.905 2.127 1.181 28.00 29Stand. SE Mean Variance SE Kurt. SE Skew. Minimum SumScalePSS .615 61.559 .378 .190 4 4120NSSQTotal 18.072 9577.34 .397 .200 19 27741Affect 2.891 1236.837 .396 .199 5 9988Affirm 2.704 1074.411 .347 .200 6 9114Aid 2.669 1047.470 .397 .200 8EDPS .479 24.060 .467 .236 1 84996The frequency counts in Table 8 show that the number ofwomen who participated in physical activity diminishes aspregnancy progresses. There are approximately even numbers ofwomen who participated in physical activity prior to pregnancybut by the third trimester of pregnancy, only one quarter of thewomen, half of the original number of exercisers, participated inphysical activity on a regular basis.97Table 8Frequency counts of women involved in physical activityExercise ExerciseTime period Yes percent No percentPrior to pregnancyFirst trimesterSecond trimesterThird trimester8167483951.3%42.4%30.4%24.7%779111011948.7%57.6%69.6%75.3%98SummaryFour two-way ANOVA's found that physical activity, duringpre-pregnancy, first trimester, second trimester or thirdtrimester of pregnancy, was not significantly related topostpartum depression. Two profile analyses indicated that noneof the demographic characteristics were significantly associatedwith postpartum depression.^The only factor found to besignificantly associated with postpartum depression was perceivedstress (by Multiple regression). A Mann-Whitney U analysis alsofound Perceived stress to be significantly associated withphysical activity during the first trimester of pregnancy.99DISCUSSIONThe incidence of postpartum depression in this studycorresponded quite closely with that of other studies(Steiner, 1990). In the present study, the reported incidence ofpostpartum depression, using a cut-off score of 10 or higher onthe Edinburgh Depression Scale (EPDS), was 27%. This wasslightly higher than rates found in previous studies because thecut-off score used in the present study was lower. A lower cut-off for depression was decided upon because of a recommendationfrom an earlier study (Harris, Huckle, Thomas, Johns & Fung,1989). If the cut-off had been 12 here instead of 10, as in someprevious studies, the incidence of postpartum depression wouldhave been 17.1%. This percentage corresponds to the range ofpercentages cited previously (Cox, Holden & Sagovsky, 1987).Because the incidence was within the range of previously reportedpostpartum depression rates, this study assumed that the cases ofpostpartum depression found were actual cases.It must be remembered that since the sample was not arandom sample and only 53% (N=220) responded to allquestionnaires, no firm conclusions can be made from this study.Since the postpartum measure was completed in the subjects homessix weeks later than the other measures, many subjects forgot orsimply did not send in this questionnaire. It was thoughtimportant that all subjects complete the postpartum measure atthe six week postpartum mark, although this time was arbitrarily100decided upon. To help ensure that this happened, each subjectreceived a phone-call in their sixth week postpartum to remindthem to complete and send in their Edinburgh PostpartumDepression Questionnaires. Postpartum depression rates tend tovary depending on the time of measurement, therefore to beconsistent within the study the same time of measurement wasrequired for all subjects. The Edinburgh scale itself has beentested for and used previously during the sixth week postpartum(Harris, Huckle, Thomas, Johns & Fung, 1989). For the abovereasons, only one follow-up call was made.Potential relationships of physical activity with postpartumdepression can now be explored. Firstly, physical activity,prior to or during any of the three trimesters of pregnancy, wasnot found to be significantly associated with a lower mean scoreof postpartum depression. The hypothesis that participation inregular physical activity during the pre-pregnancy and pregnancyperiod would be associated with a lower mean score of postpartumdepression than with those who did not particippate in physicalactivity was therefore not supported. No relationship betweenpostpartum depression and physical activity was established. Thequestion then is raised as to why no relationship betweenphysical activity and postpartum depression was found.Four two-way ANOVA's explored the relationship betweenphysical activity and postpartum depression separately for fourtime periods. These analyses did not take into account apossible cumulative effect of physical activity throughout the101four time periods. For example, did women who exercised duringall four time periods have a lower postpartum depression rating?Only 51.3% of the women were involved in physical activity priorto pregnancy. This percentage diminished to 24.7% of women bythe third trimester of pregnancy. Again, because of the lowresponse rate and low numbers of women participating in physicalactivity, a replication study would be in order.Individual studies in the literature point to the possiblepreventative powers of physical activity although this avenue hasnot been explored in depth (Morgan, 1987). For example, it isnot known what type, duration, intensity or frequency of physicalactivity is needed in order to help reduce mental health problems(eg. anxiety, stress, moderate depression) from occurring.Physical activity may also play a role in preventing certainmental health disorders from occurring but not others such aspostpartum depression.The exercise measurement used in this study, althoughcorrelated with measures of physical fitness, was not detailed.Since the same information about physical activity was desiredfor each of the four time periods (pre-pregnancy, first, secondand third trimester of pregnancy), one simple questionnaire waspreferred over four complex questionnaires. The women were alsoanswering the questions retrospectively, looking back on the lastyear of their life and answering questions pertaining to thattime period. The exact type, frequency, intensity and durationof exercise was not determined. It may be the case that a slight102advantage in preventing postpartum depression does exist forthose who exercise at a certain level or at certain times.However, large population studies might be required to detectthat advantage and the conclusion would relate to trends within acomplex phenomenon, rather than specific cause and effectconclusions.Since it is not known how long the physiological outcomes ofexercise last (Ransford, 1982), it may be that physical activityhad no effect on postpartum depression because the physiologicalchanges incurred from exercise had worn off by the time of onsetof postpartum depression. It is also not known how long thepsychological benefits of exercise last. For example, physicalactivity has been found to be associated with an increased self-confidence and emotional stability which in turn are associatedwith lower depression levels (Lobstein, Mosbacher & Ismail,1983). If indeed physical activity during pregnancy increasedself-confidence and emotional stability, these effects may havediminished by six weeks postpartum and therefore would not affectthe postpartum depression level.Something within the mystery of postpartum depression itselfcould offer an explanation as to why physical activity in thepresent study was not associated with postpartum depression. Theorigins of postpartum depression are still not known (Gitlin &Pasnau, 1989). The physiological and psychological changes thatoccur from exercise do not seem to affect postpartum depressioneven though they have helped to reduce the severity of other103forms of depression. There may be an unknown factor concerningpostpartum depression that makes it impossible to reduce itsoccurrence through exercise.In another correlational, pencil and paper, retrospectivestudy, physical activity has been associated with a reduction ofpostpartum blues (Stephenson, 1991). Postpartum blues has alsobeen linked to postpartum depression (Cox, Connor & Kendell,1982). However, throughout the literature different factors havebeen found to be related to postpartum depression than thoseassociated with postpartum blues. It may be that the beneficialeffects of physical activity are short term and thereforephysical activity was found to be associated with postpartumblues because the blues occur as early as the third or fourth dayafter childbirth. Postpartum depression does not occur untilweeks later and the changes induced from physical activity duringpregnancy may not have a sufficientlythat lasting effect.The present author recommends that future studies on thesame topic use a measure of exercise that can indicate thecumulative effect of exercise over time. Also, since physicalactivity is an effective treatment for clinical depression(Greist, Klein, Faris, Gurman & Morgan, 1979; Greist, 1987), itwould be interesting to see if exercise can effectively treatpostpartum depression. The reason why no relationship betweenphysical activity and postpartum depression was found in thepresent study may become evident in further research concerningexercise as treatment for postpartum depression.104A multiple regression analysis addressed the question ofwhether higher perceived stress and lower social support would berelated to a higher incidence of postpartum depression.Perceived stress was found to account for 22% of the variance indepression scores. Perceived stress was also found to besignificantly associated with postpartum depression but socialsupport was not found to be significantly associated withpostpartum depression. The relationship between perceived stressand postpartum depression is that a higher perceived stress scoreis related to a higher likelihood of postpartum depression. Therelationship of social support with postpartum depression was notstatistically significant (see Appendix I) although it was in theexpected direction (low social support and high depression).The above findings give partial support to previous studiesthat found low social support and high life stress to bepredictors of postpartum depression (Paykel, Emms, Fletcher &Rassaby, 1980; O'Hara, 1986; Mercer & Ferketich, 1988). Thesestudies were only partially supported because stress and notsocial support was found to be significantly related topostpartum depression. This study also supported Paykel et al's(1980) statement that perceived stress is a better predictor ofdepression than other life event scores (Paykel, Emms, Fletcher &Rassaby, 1980 and O'Hara, 1986) because of the significantrelationship found between perceived stress and postpartumdepression.The relationship between physical activity during the first105trimester of pregnancy and perceived stress was significant (seeAppendix H, Table H-1). Physical activity during pre-pregnancyand during the second and third trimesters of pregnancy were notfound to be significantly related to perceived stress.Specifically, the relationship between physical activity duringthe first trimester of pregnancy and perceived stress suggestedthat those involved in physical activity during the firsttrimester of pregnancy had lower ratings of perceived stress.This relationship of physical activity with perceived stresssupported previous studies that found physical activity to berelated to reduced stress (Plante & Rodin, 1990 and Norwell,Martin, & Salamon, 1991).It is interesting to note that perceived stress was found tobe associated with postpartum depression and that physicalactivity (during the first trimester of pregnancy) was associatedwith perceived stress yet physical activity was not associatedwith postpartum depression. Perceived stress appears to be amediating variable between postpartum depression and physicalactivity.Fleming, Baum and Singer (1984) describe stress as closelylinked with coping and part of a process involving environmentalevents, psychosocial processes, and physiological response. Theyalso describe a link between coping and perceived control. Therelationship between physical activity and stress may lie in thelink between perceived control and coping. Physical activity, asmentioned in the literature review, gives participants a feeling106of mastery and therefore more control and general confidenceabout various situations (Danskin & Crow, 1981). It could bethat because of this sense of mastery, individuals involved inphysical activity perceive a lower level of stress and are inturn better able to cope with the stress they experience. Lazarus(1975) proports that physiological changes associated withfitness training affect the adaptation strategies used to handlestress and emotions.Practical clinical applications can be drawn from theinformation that perceived stress was a mediating variablebetween physical activity and postpartum depression. Physicalactivity may indirectly have an effect on postpartum depression.Clinicians could recommend physical activity to pregnant women,especially in the second and third trimesters, with the hopes ofthose women also having a lower stress level and in turn a lowerscore of postpartum depression. It was found that stress duringpregnancy was associated with postpartum depression, which occursmonths later, yet physical activity during pregnancy may affectthe stress during pregnancy which in turn may affect postpartumdepression.Possible relationships of various demographiccharacteristics (such as age, income level, education,complications with pregnancy) with postpartum depression wereexplored by two profile analyses. The two profiles were bothfound to be parallel, but there was no significant differencefound between the profiles (see Figures 3 and 4). Specifically,107this indicated that the demographic characteristics of: age;household income; occupation; weight gain during pregnancy;complications during pregnancy; being separated from baby atbirth; ratings of how physical activity affects well-being;length of pregnancy; birthweight of baby; type of delivery;number of complications with baby; number of complications withmom; the total number of pregnancies; number of pregnancies past20 weeks; number of births; and number of children, were allunrelated to postpartum depression. These findings areconsistent with findings of past studies on postpartum depression(Unterman, Posner & Williams, 1990; Gotlib, Whiffen, Mount, Milne& Cordy, 1989).Descriptive statistics were used to compare the socialsupport and perceived stress scores with normative data fromprevious studies. The mean scores on the subscales of theNorbeck Social Support Scale (NSSQ) (mean total social support=188, mean affect= 67, mean affirm= 62 and mean aid= 59) werefound to be substantially lower than those reported by Norbeck,Lindsey and Carrieri (1981) (mean total social support= 281, meanaffect= 101, mean affirm= 92 and mean aid= 87) and Byers andMullis (1987) (mean total social support= 263, mean affect= 91,mean affirm= 86 and mean aid= 86). In the two studies citedabove, the NSSQ was administered to psychiatric inpatients (Byers& Mullis, 1987), to primarily female first-year graduate (M.S.)students in nursing and to senior nursing students (Norbeck,Lindsey & Carrieri, 1981). The differences in subject108populations may explain the differences found in the scores. Inthis study, lower ratings of social support may have been foundfor a variety of reasons. One reason may be that the subjectswere in the hospital when completing the questionnaire. Sincechildbirth is a traumatic experience for some women, thevolunteers may have been more tired and emotional than usual.Their extreme emotions and lack of energy may have had an effecton the way they scored on the social support scale. Thedifference in means of social support scores between the presentstudy and previous studies may also indicate that the NSSQ is notreliable when used on different populations or situations. Thedifference in means may also signify that this population did nothave as much social support as other populations.The perceived stress scores (measured by the PerceivedStress Scale) were found to be comparable to those in previousdata. For example, this study found the mean perceived stressscore to be 25.28 and previous studies have found means of 23.18,23.67 in male and female student samples, 25.0 in a smokingcessation sample, 23.57 and 25.71 in female student samples and25.6 in a community sample (Cohen, Kamarck & Mermelstein, 1983).The standard deviations and ranges for the perceived stressscores in this study are also similar to those found in Cohen,Kamarck & Mermelstein's (1983) study. The perceived stress ofthe present population coincided with the norms from previousstudies.The frequency counts of women participating in physical109activity during the four time periods lend support to the generalbelief that the activity level of pregnant women drops as womenprogress through their pregnancies (see Table 8). For specificinformation of the reasons why women in this study changed theirphysical activity level see Appendix G.In review, no relationship was found between physicalactivity during pre-pregnancy or during the three trimesters ofpregnancy and postpartum depression. Perceived stress scoreswere found to be significantly related to postpartum depressionbut no relationship between low social support and postpartumdepression was found. No demographic characteristics were foundto be related to postpartum depression. The relationship foundbetween physical activity during the first trimester of pregnancyand perceived stress implied that stress was a mediating variablebetween physical activity and postpartum depression. The amountof physical activity during pregnancy decreases as the pregnancyprogresses.Recommendations for further research are made in thefollowing areas: exercise as treatment for postpartum depression,the potential of exercise in reducing the occurrence ofdepression, and the relationship between physical activity andperceived stress, and the role of stress as a mediator betweenphysical activity and postpartum depression.110SUMMARYThis study combined the two topics of exercise/mental healthand postpartum depression. Postpartum depression over the yearsgenerated considerable research interest while never revealingthe mystery of its cause or giving hints of factors that couldplay a role in preventing or limiting its occurrence. Therelationship between exercise and mental health has also beenextensively studied. While many studies have been concerned withexercise as treatment for various mental health problemsincluding depression, studies have only begun to investigate therole that exercise may play in reducing the occurrence of mentalhealth problems such as depression. While attempting to connectthe two broad topics of postpartum depression and exercise/mentalhealth, this study also retrospectively investigated the role ofexercise in prevention of postpartum depression. The generalpurpose of the study was to identify variables that might beuseful in preventing postpartum depression from occurring in thefuture, specifically looking at whether physical activity (anunexplored variable up until this point) had any relationship topostpartum depression and in turn whether physical activity wasassociated with other variables (such as perceived stress andsocial support) that were related to postpartum depression.The present study also chose to measure stress and socialsupport, the two variables found to be most consistently relatedto postpartum depression (Paykel, Emms, Fletcher & Rassaby, 1980;111O'Hara, 1986; Mercer & Ferketich, 1988) in the literature.Information about the demographic characteristics of the subjectswas also acquired.The Demographic Questionnaire, developed by the researcher,was checked for understanding. The other four questionnairesused were standardized questionnaires. The Perceived StressScale was chosen because perceived stress has been shown to be abetter predictor of depression than life stress (Cohen, Kamarck &Mermelstein, 1983). The Norbeck Social Support Scale was chosento measure social support because it has been shown to be bothvalid and reliable for a clinically depressed population (Byers &Mullis, 1987). Exercise was measured by a question aboutphysical activity and was included in the Lifestyle HabitQuestionnaire. The physical activity question used is associatedwith measures of physical fitness (Schecktman, Barzilai, Rost &Fisher, 1991). This question was asked four times, oncepertaining to physical activity during pre-pregnancy, once forthe first trimester of pregnancy, once for the second trimesterof pregnancy and once for the third trimester of pregnancy.Finally, the Edinburgh Depression Scale was used to measurepostpartum depression because it is the only standardized scaledesigned specifically for postpartum depression (Cox, Holden &Sagovsky, 1987).Volunteer subjects (104) from two Lower Mainland hospitalswere contacted to participate in the study. Those consenting toparticipate (220) were given five questionnaires to complete.112The demographic questionnaire, the Perceived Stress Scale, theNorbeck Social Support Scale and the physical activityquestionnaire (which also included additional items) werecompleted in the days following childbirht while the subjectswere in the hospitals after having their babies. The fifthquestionnaire, the Edinburgh Depression Scale, was taken home andcompleted by the subjects when their babies were six weeks old.This questionnaire was mailed to the researcher.Four two-way ANOVA's addressed the question of whether ornot postpartum depression was related to physical activity duringpre-pregnancy or during each of the three trimesters ofpregnancy. Postpartum depression was not shown to be related toparticipation in physical activity during any of the four timeperiods.A Multiple Regression analysis found perceived stress to besignificantly associated with postpartum depression but did notfind social support to be significantly related to postpartumdepression. This only partially agreed with previous literaturethat found high stress as well as low social support to beassociated with postpartum depression. A Mann-Whitney U analysisfound physical activity during the first trimester of pregnancyto be associated with perceived stress. This finding as well asthe finding of a significant relationship between perceivedstress and postpartum depression implied that perceived stresswas a mediating factor between physical activity and postpartumdepression.113No demographic characteristics were found to be associatedwith postpartum depression. This was shown through two profileanalyses that tested for parallelism and coincidence. It wasalso found that participation in physical activity diminished aspregnancy progressed.As mentioned previously, this study did not totally supportthe main thesis question of whether physical activity during pre-pregnancy and pregnancy was related to postpartum depression butdid find that physical activity (during the first trimester ofpregnancy) was associated with perceived stress (the onlyvariable found to be significantly associated with postpartumdepression). In spite of the lack of a direct relationship ofphysical activity with postpartum depression, the possibilityremains that physical activity may be an effective treatment forpostpartum depression. The likelihood that stress was a mediatorbetween physical activity and postpartum depression also haspractical clinical implications. Physical activity in the firsttrimester of pregnancy may have an indirect effect on postpartumdepression.Much remains to be investigated regarding the possiblepreventative powers of physical activity. More longitudinalcontrolled studies on physical activity and its relationship tomental health are needed. A combination of physiological andpsychological theories must be developed that combine physicalactivity and depression. The factors that induce postpartumdepression must be found so that the frequency with which it114occurs may be reduced.Delimitations Even though there are many confounding variables, this studyonly controlled for the two main predictors of postpartumdepression: social support and perceived stress. In an attemptto rule out extremes, women who were at particularly high riskfor incurring postpartum depression were eliminated from thestudy. These included women with a total absence of socialsupport, women who were unwed teen mothers and women who wereseparated from their infants for 48 hours or more immediatelyafter birth.The question used to measure physical activity was designedto determine whether or not women were involved in physicalactivity that would maintain or improve fitness. It did notobtain information about the type of physical activity they wereinvolved in, or frequency and length of exercise period.Limitations There are several limiting conditions or restrictiveweaknesses of the study. The use of self-report measures assumesthat the subjects are answering honestly. There was no check tovalidate their actual responses and it was not known if thesubjects understood the questions. The retrospective nature of115the study also creates a problem in that again there was noconfirmation of the responses with the action that took place.The response rate of 52% and lack of randomization ofsubjects raises questions about the subjects that dropped out ofthe study. Those that did respond may be unusual in some way.The sample was likely biased because of self-selection toparticipate or not participate in the study.Not all women who had postpartum depression may have beenidentified. The women may have developed postpartum depressionat the eight week mark yet the postpartum depression measure wascompleted at six weeks postpartum.Future directionsAs a result of the 52% response rate, a replication studywould be in order to detect any advantage that may exist forthose who exercise at a certain intensity level or at specifictimes. A large population sample may be required to detect thatadvantage.Physical activity did not have any long term effects onmental health (postpartum depression) in the present study yetprevious studies have found physical activity to be associatedwith long term changes in mental health. This area of the longterm effects of physical activity and its effect on mental health(general depression) needs to be explored further. It is notknown what duration, frequency, intensity and type of exercise is116needed in order for long term and lasting effects on mentalhealth to occur.A confirmation study of the relationship between postpartumblues and physical activity is needed as many of the weaknessesof the present study were also evident in the postpartum bluesstudy.The use of exercise as treatment for postpartum depressionis another avenue to explore. 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British Journal of Psychiatry, 146, 622-627.128Appendix ADemographic Information Ouestionnaire AGE a) under 20 yrsb) 20 to 25 yrsc) 26 to 30 yrsd) 31 to 35 yrse) over 35MARITAL STATUS married single common-law (please circle one)EDUCATIONAL LEVEL ATTAINEDa) grade 8 or lessb) high schoolc) lyr technical school or colleged) 2yr technical school or collegee) university degreef) graduate degreeg) other (specify)FAMILY INCOME BRACKETa) 20,000 or lessb) 21,000-40,000c) 41,000-60,000d) 61,000-75,000e) over 75,000OCCUPATIONa) housewifeb) professionalc) businessd) tradee) otherLENGTH OF PREGNANCY (in weeks)a) under 32 weeksb) 32 to 36 weeksc) 37 to 42 weeksd) over 42 weekse) over 42 weeksWEIGHT GAIN DURING PREGNANCY (in pounds)a) 20 lbs or lessb) 21 to 25 lbsc) 26 to 35 lbsd) 36 to 46 lbse) 47 lbs or more129COMPLICATIONS DURING PREGNANCYa) gestational diabetesb) bleedingc) high blood pressured) nothing out of the ordinarye) other (please specify)BIRTH OUTCOME (weight of baby)a) under 5 lbsb) 6 to 8 lbsc) 9 or 10 lbsd) over 10 lbsTYPE OF DELIVERYa) caesarianb) forcepsc) suction/vacuumd) spontaneous vaginalCOMPLICATIONS WITH BABY yes no If yes what?a) breathing problemsb) jaundicec) birth defectsd) spent time in special care nurseryd) other (please specify)COMPLICATIONS WITH MOM yes no If yes what?a) excessive bleedingb) infectionc) high blood pressured) other (please specify)WERE YOU SEPARATED FROM YOUR BABY? If yes for how long?a) less than 24 hoursb) one or two daysc) three to five daysd) more than five daysREPRODUCTIVE HISTORYtotal # of pregnanciesa) oneb) 2 - 3c) 4 - 6d) more than 6# of pregnancies past 20 weeksa) oneb) 2 - 3c) 4 - 6d) more than 6130# of birthsa) oneb) 2 - 3c) 4 - 6d) more than 6living childrena) oneb) 2 - 3c) 4 - 6d) more than 6Rate how regular exercise affects emotional well being on a scaleof 1 to 5.1. always influences positively2. sometimes influences positively3. has no effect4. sometimes influences negatively5. always influences negatively131Appendix BPerceived Stress Scale The questions in this scale ask you about your feelings andthoughts during the last month. In each case, you will be askedto indicate how often you felt or thought a certain way.Although some of the questions are similar, there are differencesbetween them and you should treat each one as a separatequestion. The best approach is to answer each question fairlyquickly. That is, don't try to count up the number of times youfelt a particular way, but rather indicate the alternative thatseems like a reasonable estimate.For each question choose from the following alternatives:0. never1. almost never2. sometimes3. fairly often4. very often1. In the last month, how often have you been upset because ofsomething that happened unexpectedly?2. In the last month, how often have you felt that you wereunable to control the important things in your life?3. In the last month, how often have you felt nervous and"stressed"?4. In the last month, how often have you dealt successfully withirritating life hassles?5. In the last month, how often have you felt that you wereeffectively coping with important changes that were occurringin your life?6. In the last month, how often have you felt confident aboutyour ability to handle your personal problems?7. In the last month, how often have you felt that things weregoing your way?8. In the last month, how often have you found that you couldnot cope with all the things that you had to do?9. In the last month, how often have you been able to controlirritations in your life?10. In the last month, how often have you felt that you were ontop of things?11. In the last month, how often have you been angered because ofthings that happened that were outside of your control?12. In the last month, how often have you found yourself thinkingabout things that you have to accomplish?13. In the last month, how often have you been able to controlthe way you spend your time?14. In the last month, how often have you felt difficulties werepiling up so high that you could not overcome them?132Appendix CLifestyle Habit Questionnaire1. Prior to pregnancy were you participating in any regularactivity or program (either on your own or in a formal class)which would improve or maintain your physical fitness? yes or no2a. In your first three months of pregnancy were youparticipating in any regular activity or program (either on yourown or in a formal class) designed to improve or maintain yourphysical fitness? yes or no2b. Was this more, less or the same amount of activity from theperiod prior to pregnancy?2c. If your pattern of activity changed from prior to pregnancyto your first trimester of pregnancy what was the most importantreason for this change?a) advice from a professionalb) encouragement from significant othersc) sicknessd) tirednesse) uncomfortablenessf) cultural reasonsg) other (please specify)3a. In your second three months of pregnancy were youparticipating in any regular activity or program (either on yourown or in a formal class) which would improve or maintain yourphysical fitness? yes or no3b. Was this more, less or the same amount of activity from theperiod prior to pregnancy?3c. If your pattern of activity changed was what was the one mostcompelling reason for this change?a) advice from a professionalb) encouragement from significant othersc) sicknessd) tirednesse) uncomfortablenessf) cultural reasonsg) other (please specify)3d. Did your activity in the second three months of pregnancychange from the first three months of pregnancy?3e. Was this more or less activity?1333f. If your pattern of activity changed what was the one mostcompelling reason for this change?a) advice from a professionalb) encouragement from significant othersc) sicknessd) tirednesse) uncomfortablenessf) cultural reasonsg) other (please specify)4a. In the last three months of pregnancy were you participatingin any regular activity or program (either on your own or in aformal class) designed to improve or maintain your physicalfitness? yes or no4b. Was this more, less or the same amount of activity from theperiod prior to pregnancy?4c. If your pattern of activity changed what was the one mostcompelling reason for this change?a) advice from a professionalb) encouragement from significant othersc) sicknessd) tirednesse) uncomfortablenessf) cultural reasonsg) other (please specify)4d. During the last three months of pregnancy did your activitychange from the second three months of pregnancy? yes or no4e. If your pattern changed was this more, less or the sameamount of activity from the second three months?4f. If your pattern of activity changed what was the one mostcompelling reason for this change?a) advice from a professionalb) encouragement from significant othersc) sicknessd) tirednesse) uncomfortablenessf) cultural reasonsg) other (please specify)134Appendix DNorbeck Social Support ScaleList each significant person in your life on the right. Considerall the persons who provide personal support for you or who areimportant to you now.NumberDatePERSONAL NETWORKFirst name or initials^Relationship1. (34)2. (35)3. (36)4. (37)5. (38)6. (39)7. (40)8. (41)9. (42)10. (43)11. (44)12. (45)13. (46)14. (47)15. (48)16. (49)17. (50)18. (51)19. (52)20. (53)135For each person you listed, please answer the following questionsby writing in the number that applies.1= never2= a little3= moderately4= quite a bit5= a great dealQuestion 1.How much doesyou feel likedQuestion 2.this person make^How much does this person makeor loved?^you feel respected or admired?1. 1.2. 2.3. 3.4. 4.5. 5.6. 6.7. 7.8 8.9. 9.10. 10.11. 11.12. 12.13. 13.14. 14.15. 15.16. 16.17. 17.18. 18.19. 19.20. 20.136QuestionHow muchperson?3.^ Question 4.can you confide in this How much does this person agreewith or support your actions orthoughts?1. 1.2. 2.3. 3.4. 4.5. 5.6. 6.7. 7.8. 8.9. 9.10. 10.11. 11.12. 12.13. 13.14. 14.15. 15.16. 16.17. 17.18. 18.19. 19.20. 20.137Question 5.^ Question 6.If you needed to borrow $10, a If you were confined to bed forride to the doctor, or some^several weeks, how much couldother immediate help, how much this person help you?could this person usually help?1.^ 1.2. 2.3. 3.4. 4.5. 5.6. 6.7. 7.8. 8.9. 9.10. 10.11. 11.12. 12.13. 13.14. 14.15. 15.16. 16.17. 17.18. 18.19. 19.^20.^ 20.138For each person you listed please answer the following questionsby writing in the number that applies.Question 7.^ Question 8.How long have you known this^How frequently do you usuallyperson? have contact with this person?(phone calls, visits, orletters)1= less than 6 months 1= once a year or less2= 6 months to 1 year 2= two or three times a year3= 2 to 3 years 3= once a month4= 4 to 5 years 4= once a week5= more than 5 years 5= daily1. 1.2. 2.3. 3.4. 4.5. 5.6. 6.7. 7.8. 8.9. 9.10. 10.11. 11.12. 12.13. 13.14. 14.15. 15.16. 16.17. 17.18. 18.19. 19.20. 20.139Question 9.During the past year, have you lost any important relationshipdue to moving, a job change ,divorce or separation, death, orsome other reason?If YES, check the category(s) of persons who are no longeravailable to you.Spouse or partnerFamily or RelativesFriendsWork or School AssociatesNeighboursHealth Care ProvidersCounsellor or TherapistMinister/Priest?RabbiOtherHow much support did this person (or persons) provide for youduring the past six months?0= none at all1= a little2= moderately3= quite a bit4= a great deal140Appendix EEdinburgh Postnatal Depression Scale (EPDS) As you have recently had a baby, we would like to know how youare feeling. Please UNDERLINE the answer which comes closest tohow you have felt IN THE PAST 7 DAYS, not just how you feeltoday.Here is an example, already completed.I have felt happy:Yes, all the timeYes, most of the time No, not very oftenNo, not at allThis would mean: "I have felt happy most of the time" during thepast week. Please complete the other questions in the same way.In the past 7 days1. I have been able to laugh and see the funny side of thingsAs much as I always couldNot quite so much nowDefinitely not so much nowNot at all2. I have looked forward with enjoyment to thingsAs much as I ever didRather less than I used toDefinitely less than I used toHardly at all3. I have blamed myself unnecessarily when things went wrongYes, most of the timeYes, some of the timeNot very oftenNo, never4. I have been anxious or worried for no good reasonYes, quite a bitHardly everYes, sometimesNo, not muchNo, not at all5. I have felt scared or panicky for no very good reasonYes, quite a lotYes, sometimesNo, not muchNo, not at all6. Things have been getting on top of meYes, most of the time I haven't been able to cope at allYes, sometimes I haven't been coping as well as usualNo, most of the time I have coped quite wellNo, I have been coping as well as ever1417. I have been so unhappy that I have had difficulty sleepingYes, most of the timeYes, sometimesNot very oftenNo, not at all8. I have felt sad or miserableYes, most of the timeYes, quite oftenNot very oftenNo, not at all9. I have been so unhappy that I have been cryingYes, most of the timeYes, quite oftenOnly occasionallyNo, never10. The thought of harming myself has occurred to meYes quite oftenSometimesHardly everNever142Appendix FEthical review documents Project DescriptionLIFESTYLE HABITS AND COPING AFTER CHILDBIRTHRESEARCHERS: Sheryl Stephenson 882-4152 UBCDr. Sharon Bleuler 822-4267 UBCThis project is a requirement of graduation for a Masters degreefrom the University of British Columbia.This project is designed to investigate the relationship betweenlifestyle habits of the pregnant woman and the ability to adjustto life after childbirth. This information may help others inadjusting to life after childbirth.Confidentiality will be maintained by the use of codes instead ofnames on the questionnaires. The completed questionnaires willthen be accessible only to the researchers and members of thestudent's MPE Committee (Dr. Sue Crawford and Ms Alison Rice).The total amount of time required for your participation isapproximately 1 hour (for responding to five questionnaires).Please feel free to direct any further enquiries to one of theresearchers above.You have the right to refuse to participate or to withdraw at anytime during the study. Be assured that refusal to participate orwithdrawal at anytime will not jeopardize your health care.If you can assist by volunteering for this project pleasecomplete the attached consent form and return it to the nurse ora research assistant. The first four questionnaires can befilled out at any time. The fifth questionnaire is to be filledout in the sixth week after the birth of your child. You willalso be given a stamped self-addressed envelope in which to mailthe questionnaires to the researcher. If you are unable to dothis you have the option of calling the researcher to come andpick it up. You will also be receiving a phone call in your 6thweek after the birth of your child to check on your progress.Thank-you for taking time to read this.SincerelySheryl StephensonMPE UBC Student143Consent FormI (print name) ^have read the description of the project and understand that anyindividual responses and my identity will be kept confidential: Iunderstand what will be required of me and the time involved: Iam aware that it is my right to refuse to participate or withdrawat any time and that refusal to participate or withdrawal willnot jeopardize my health care. I have read who the investigatorsare and what the procedures of this project are and consent tobeing a volunteer for this research project.SIGNED^ADDRESS PHONE#DATEPlease check this box if you have received and read thedescription of the project and have received a copy of thisconsent form for your records.144Ethical review certificate of approval30 June 1992Sheryl Stephenson7600 Glover RoadLangley, BCV3A 6H4Dear Sheryl:On behalf of the Nursing Research Committee, I would like toinform you that your request to conduct research at SurreyMemorial Hospital has been accepted.I understand that the one outstanding issue regarding who wouldobtain consent from the participants has been addressed. I lookforward to receiving your written notification of this change.Please contact Mrs. Morah Avery, Head Nurse, 3 East as soon asyou are ready to begin your study.We look forward to hearing about the results you obtain and theimplications these findings will have on the fields of educationand nursing.Good luck.Yours truly,Vivian GiglioHead Nurse, 2 SouthVG:mkjc.c. Research CommitteeMorah Avery, Head Nurse, 3 EastKathy Kinloch, Vice President (Nursing)Alison Rice, UBC, Faculty of NursingDr. Sharon Bleuler, UBC, Faculty of Physical EducationHNS\2S\RESEARCH.LTR13750 - 96th Avenue, Surrey, British Columbia V3V 1Z2 Tel. (604) 581-2211 Fax. 588-3382Dr. R.D. pratleyDirector, Research Servicesand Acting Chairman145Hospital letter of approvalThe University of British Columbia^B92-115Office of Research ServicesBEHAVIOURAL SCIENCES SCREENING COMMITTEE FOR RESEARCHAND OTHER STUDIES INVOLVING HUMAN SUBJECTSCERTIFICATE^of APPROVALINVESTIGATOR:UBC DEPT:INSTITUTION:TITLE:NUMBER:CO-INVEST:APPROVED:Bleuler, S.Phys Ed & RecreationUBC CampusRegular physical activity during theprenatal period and its relationship to theincidence of postpartum depression'B92-115Stephenson, S.APR 3 0 1992The protocol describing the above-named project has beenreviewed by the Committee and the experimental procedures werefound to be acceptable on ethical grounds for researchinvolving human subjects.THIS CERTIFICATE OF APPROVAL IS VALID FOR THREE YEARSFROM THE ABOVE APPROVAL DATE PROVIDED THERE IS NOCHANGE IN THE EXPERIMENTAL PROCEDURES146Appendix GFrequency Scores of the Demographic variables and items from TheLifestyle Habit Questionnaire To gain a picture of the subjects from this study thefrequency of scores from the demographic questionnaire wereoutlined below. This gave important information about thecharacteristics of this population.AGE^ frequency^percent<20 years^ 8^4.8%20-25 years 47 28.3%26-30 years 67 40.4%31-35 years^39^23.5%>35 years 5 3.0%166MARITAL STATUS^frequency^percentmarried^ 133^80.1%single 13 7.8%common-law 3 12.0%166EDUCATIONAL LEVEL^frequency^percent<grade 8^ 1^ .6%grade 9-12 20 12.0%high-school 70 41.9%1 yr technical^29^17.4%university degree^24 14.4%graduate degree 12 7.2%other^ 7 6.6%167TOTAL HOUSEHOLD INCOME frequency^percent<20,00021,000-40,00041,000-60,00061,000-80,00081,000-100,000OCCUPATIONhomemakerprofessionalbusinesstradeotherLENGTH OF PREGNANCY<31 weeks^ 2^1.2%31-36 weeks 5 3.0%36-42 weeks 146 88.5%42 or more 12^7.3%16529 18.8%40 26.0%50 32.5%27 17.5%8 5.2%154frequency percent68 41.0%35 21.1%29 13.3%9 5.4%5 19.3%166frequency percent147WEIGHT GAIN DURING PREGNANCY frequency^percent<20 lbs^ 25^15.1%21-25 lbs 27 16.3%26-35 lbs 63 38.0%36-46 lbs 35^21.1%47 lbs +^ 16 9.6%166COMPLICATIONS DURING PREGNANCYgestational diabetesbleedinghigh blood pressurenothing out of the ordinaryotherOUTCOME OF BABY (WEIGHT OF BABY)<5 lbs^ 1^.6%5-8 lbs 104 62.3%8-10 lbs 59 35.3%over 10 lbs 3^1.8%167TYPE OF DELIVERY^frequency^percentcaesarian^37^22.2%forceps 8 4.8%suction 17 10.2%spontaneous vaginal 105^62.9%167COMPLICATIONS WITH THE BABY frequency^percentno complications^131^78.4%complications present^36 21.6%167NUMBER OF COMPLICATIONS WITH THE BABY frequency percent0 130 77.8%1 29 17.4%2 7 4.2%3 1 .6%167COMPLICATIONS WITH MOTHER DURING OR AFTER DELIVERYfrequency^percentno complications^146 87.4%complications present^21^12.6%167NUMBER OF COMPLICATIONS WITH MOTHERfrequency percent0 146 87.4%1 17 10.2%2 4 2.4%167frequency percent14 8.4%15 9.0%11 6.6%112 67.5%14 8.4%166frequency percent148BABY AND MOTHER SEPARATED AT BIRTHfrequency^percentnot separated^125 74.9%yes, for < 24 hrs.^37^22.2%yes, for 1-2 days 3 1.8%yes for more than 5 days^5^1.2%167TOTAL NUMBER OF PREGNANCIES EXPERIENCEDfrequency^percent1^58 34.7%2-3 82^49.1%4-6^27 16.2%167NUMBER OF PREGNANCIES EXPERIENCED THAT HAVE GONE PAST 20 WEEKSfrequency^percent1^73 43.7%2-3 79^47.3%4-6^15 9.0%167NUMBER OF BIRTHS EXPERIENCEDfrequency^percent1^71 42.5%2-3 81^48.5%4-6^15 9.0%167NUMBER OF CHILDRENfrequency^percent1^71 42.5%2-3 81^48.5%4-6^15 8.4%167RATING OF THE INFLUENCE OF PHYSICAL ACTIVITY ON WELL BEINGfrequency^percentalways influences positively^97 59.1%sometimes influences positively^61^37.2%has no effect^ 5 3.0%sometimes influences negatively^1 .6%always influences negatively^0^0164The frequencies of items from the Lifestyle HabitQuestionnaire were outlined below. These items gave informationabout the exercise habits of the women and how these habits maybe different than the habits of non-pregnant women.PHYSICAL ACTIVITY PRIOR TO PREGNANCYfrequency^percentyes^81 51.3%no 77^48.7%158149PHYSICAL ACTIVITY IN 1ST TRIMESTER OF PREGNANCYfrequency^percentyes^67 42.4%no 91^57.6%158PHYSICAL ACTIVITY IN 2ND TRIMESTER OF PREGNANCYfrequency^percentyes^48 30.4%no 110^69.6%158PHYSICAL ACTIVITY IN 3RD TRIMESTER OF PREGNANCYfrequency^percentyes^39 24.7%no 119^75.3%158PHYSICAL ACTIVITY LEVEL IN 1ST TRIMESTER OF PREGNANCY AS COMPAREDTO PRIOR TO PREGNANCYfrequency percentmore 9 5.7%less 48 30.6%equal 100 63.7%157PHYSICAL ACTIVITY LEVEL IN 2ND TRIMESTER OF PREGNANCY AS COMPAREDTO PRIOR TO PREGNANCYfrequency percentmore 13 8.3%less 51 32.5%equal 93 59.2%PHYSICAL ACTIVITY LEVEL IN 3RD TRIMESTER OF PREGNANCY AS COMPAREDTO PRIOR TO PREGNANCYfrequency percentmore 13 8.3%less 81 51.6%equal 63 40.1%REASON FOR CHANGE IN ACTIVITY LEVEL BETWEEN PRIOR TO PREGNANCYAND 1ST TRIMESTER OF PREGNANCYfrequency percentadvice from a professional 9 5.8%encouragement from sig. other 7 4.5%sickness 19 12.2%tiredness 24 15.4%uncomfortableness 3 1.9%cultural reasons 1 .6%other reason 7 6.4%no change 83 53.2%150REASON FOR CHANGE IN ACTIVITY LEVEL BETWEEN PRIOR TO PREGNANCYAND 2ND TRIMESTER OF PREGNANCYfrequency percentadvice from a professional 12 7.7%encouragement from sig. other 6 3.8%sickness 8 5.1%tiredness 27 17.3%uncomfortableness 12 7.7%cultural reasons 1 .6other reason 12 7.7%no change 78 50.0%REASON FOR CHANGE IN ACTIVITY LEVEL BETWEEN PRIOR TO PREGNANCYAND 3RD TRIMESTER OF PREGNANCYfrequency percentadvice from a professional 17 10.9encouragement from sig. other 7 4.5%sickness 2 1.3%tiredness 42 26.9%uncomfortableness 25 16.0%cultural reasons 0 0other reason 12 7.7%no change 51 32.7%CHANGE IN LEVEL OF PHYSICAL ACTIVITY1ST TRIMESTER OF PREGNANCYfrequencyyes, it changed^64no, it remained the same^93CHANGE IN LEVEL OF PHYSICAL ACTIVITY2nd TRIMESTER OF PREGNANCYfrequencyyes, it changed^88no, it remained the same^69DURING 2ND TRIMESTER FROMpercent40.8%59.2%DURING 3rd TRIMESTER FROMpercent56.1%43.9%LEVEL OF PHYSICAL ACTIVITY DURING 2ND TRIMESTER AS COMPARED TOTHAT OF THE FIRST TRIMESTER OF PREGNANCYfrequency percentmore 22 14.0%less 45 28.7%equal 90 57.3%LEVEL OF PHYSICAL ACTIVITY DURING 3rd TRIMESTER AS COMPARED TOTHAT OF THE 2nd TRIMESTER OF PREGNANCYfrequency percentmore 13 8.3%less 81 51.6%equal 63 40.1%151REASON FOR CHANGE IN ACTIVITY LEVEL BETWEENPREGNANCY AND THE 3RD TRIMESTER OF PREGNANCYfrequencyTHE 2nd TRIMESTER OFpercentadvice from a professional^13 8.3%encouragement from sig. other 7 4.5%sickness 4 2.5%tiredness 24 15.3%uncomfortableness 10 6.4%cultural reasons 1 .6other reason 19 12.1%no change 79 50.3%REASON FOR CHANGE IN ACTIVITY LEVEL BETWEENPREGNANCY AND THE 3RD TRIMESTER OF PREGNANCYfrequencyTHE 2ND TRIMESTER OFpercentadvice from a professional^18 11.5%encouragement from sig. other 3 1.9%sickness 2 1.3%tiredness 36 22.9%uncomfortableness 30 19.1%cultural reasons 0 0other reason 15 9.6%no change 53 33.8%MOTHERS EXPERIENCING A LOSS OF AN IMPORTANT RELATIONSHIP WITHINTHE LAST YEARfrequency^percentyes^46 31.3%no 101^68.7%152Appendix HThe relationship of physical activity and perceived stress Data from 158 subjects was analyzed to obtain information onphysical activity and its relationship to perceived stress. Aseparate Mann-Whitney U was conducted separately for the level ofphysical activity prior to pregnancy, during the first trimesterof pregnancy, during the second trimester of pregnancy and duringthe third trimester of pregnancy.As can be seen in Table H-1, results showed no significant2-tailed P (p = .30) indicating no relationship of physicalactivity in the pre-pregnancy period with perceived stress. Theresults, in Table H-1, also showed no significant 2-tailed Pscores (p = .86 and p = .84 respectively) indicating norelationship of physical activity during the second or thirdtrimester of pregnancy with perceived stress. The 2-tailed P of.067 (p< .10) shown in Table H-1 suggested that a relationshipexists between physical activity during the first trimester ofpregnancy and perceived stress.153Table H-1Frequency of participation in physical activity pre-pregnancy andduring pregnancy and mean rating of Perceived Stress Scores. NumberPartici-tion inPhy. Act.MeanStressScoreRankNumberNot Part-icipationin Phy. Act.MeanStressScoreRankSig.Prior to 80 70.35 75 81.83 .3028PregnancyFirst 66 70.35 89 83.67 .0673TrimesterSecond 47 78.91 108 77.60 .8669TrimesterThird 38 79.22 117 77.60 .8465Trimester154Appendix IThe relationship of participation in physical activity and social support The data from 158 subjects was also analyzed to studyphysical activity and its relationship to Social Support. Thisanalyses was conducted separately for physical activity duringpre-pregnancy, during the first trimester of pregnancy, duringthe second trimester of pregnancy and during the third trimesterof pregnancy. As shown in Table I-1 no significant 2-tailed P(p= .35, p= .73, p= .29 and p= .73 respectively) was indicated.Physical activity was not found to be related to social support.155Table I-1Frequency of participation in physical activity pre-pregnancy andduring pregnancy and mean rating of Social Support Scores. NumberPartici-tion inPhy. Act.MeanSupportScoreRankNumberNot Part-icipationin Phy. Act.MeanSupportScoreRankSig.Prior to 75 75.57 69 69.16 .3566PregnancyFirst 61 73.86 83 71.50 .7372TrimesterSecond 43 78.10 101 70.11 .2928TrimesterThird 35 70.41 109 73.17 .7338Trimester156Appendix JLoss (measured by the Norbeck Social Support Questionnaire) andits relationship to postpartum depressionA Mann-Whitney U was used to determine whether or not lossof an important relationship would be related to postpartumdepression. A subscale of the Norbeck Social Support Scalemeasured the loss of an important relationship within theprevious year. Data from 105 subjects was obtained. As shown inTable 8, the nonsignificant 2-tailed P (p = .15) indicated thatloss was not related to postpartum depression.157Table J-1The relationship between loss of an important relationship andpostpartum depression. # who experienced Mean Dep^# who did not^Mean Dep^SigLoss^Score^experience^ScoreRank Loss^Rank32^50.14^57 42.11^.1585
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Is there a relationship between pre-natal exercise and postpartum depression
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