Rates and risk factors associated with depressive symptoms during pregnancy and with postpartum onset.

The objectives of this study were to evaluate the prevalence of depressive symptoms in the third trimester of pregnancy and at 3 months postpartum and to prospectively identify risk factors associated with elevated depressive symptoms during pregnancy and with postpartum onset. About 364 women attending antenatal clinics or at the time of their ultrasound were recruited and completed questionnaires in pregnancy and 226 returned their questionnaires at 3 months postpartum. Depressed mood was assessed by the Edinburgh Postnatal Depression Scale (EPDS; score of ≥ 10). The rate of depressed mood during pregnancy was 28.3% and 16.4% at 3 months postpartum. Among women with postpartum depressed mood, 6.6% were new postpartum cases. In the present study, belonging to a non-Caucasian ethnic group, a history of emotional problems (e.g. anxiety and depression) or of sexual abuse, comorbid anxiety, higher anxiety sensitivity and having experienced stressful events were associated with elevated depressed mood during pregnancy. Four risk factors emerged as predictors of new onset elevated depressed mood at 3 months postpartum: higher depressive symptomatology during pregnancy, a history of emotional problems, lower social support during pregnancy and a delivery that was more difficult than expected. The importance of identifying women at risk of depressed mood early in pregnancy and clinical implications are discussed.

PTSD following childbirth: a prospective study of incidence and risk factors in Canadian women.

OBJECTIVE: The goals of the present study were to estimate the incidence and course of full and partial Post-Traumatic Stress Disorder (PTSD) following childbirth and to prospectively identify factors associated with the development of PTSD symptoms at 1month following childbirth. METHODS: The sample comprised 308 women, with assessments at four time points: 25-40weeks gestation, 4-6weeks postpartum, 3 and 6months postpartum. Current and prior PTSD were assessed by the Structured Clinical Interview for DSM-IV (SCID-I) and the Modified PTSD Symptom Scale Self-Report (MPSS-SR). RESULTS: Incidence rates of PTSD varied according to time of measurement and instrument used, with higher rates of full and partial PTSD using the MPSS-SR at 1month postpartum (7.6% and 16.6%, respectively). Multivariate logistic regression showed that higher anxiety sensitivity (OR=1.75; 95% CI=1.19‒2.57, p=.005), history of sexual trauma (OR=2.81; 95% CI=1.07‒7.37, p=.036), a more negative childbirth experience than expected (OR=0.96; 95% CI=0.94‒0.98, p=.001), and less available social support at 1month postpartum (OR=0.40; 95% CI=0.17‒0.96, p=.041) independently predicted full or partial PTSD at 1month following childbirth. CONCLUSION: Our results indicate that a history of sexual trauma and anxiety sensitivity can increase the probability of developing PTSD after childbirth. The findings highlight the importance of screening and providing more tailored services for women at high risk.

Sleep problems and depressed mood negatively impact health-related quality of life during pregnancy.

The objectives of this study were to evaluate and identify determinants of health related quality of life (HRQoL) during pregnancy. Pregnant women (n = 245) completed questionnaires measuring: HRQoL (Short Form Health Survey SF-36), life stress, social support, sleep, and depressed mood in the third trimester. Demographics and medical variables were also collected. Compared to Canadian normative data, our sample scored significantly poorer on the following HRQoL domains: physical functioning, role limitations due to physical health problems, bodily pain, vitality, and social functioning. Multivariate linear regressions were used to model each of the SF-36 subscales. Experiencing sleep problems emerged as a significant determinant of poorer HRQoL in all domains, with the exception of emotional role. Higher depressed mood scores was independently associated with lower HRQoL in six of the eight domains, including bodily pain, general health, vitality, social functioning, emotional role, and mental health. Greater pregnancy-related anxiety was independently associated with lower scores on physical functioning and role limitations due to physical health problems. Women experience lower HRQoL during pregnancy, particularly in the physical domains. The importance of identifying and managing modifiable determinants early in pregnancy to enhance maternal health status is discussed.

A randomized clinical trial of exercise to alleviate postpartum depressed mood.

OBJECTIVE: To evaluate whether a 12-week home-based exercise program is more effective than usual care for alleviating depressive symptomology in the postpartum. METHODS: Eighty-eight women experiencing postpartum depressed mood were randomly assigned to a 12-week home-based exercise program or usual care. Outcomes assessed immediately post-treatment and 3-months post-treatment were the Hamilton Rating Scale for Depression (HAM-D) and Edinburgh Postnatal Depression Scale (EPDS). RESULTS: In the intention-to-treat analysis, the effect of the intervention on EPDS did not change from 3 to 6 months evaluations, but was modified by the baseline EPDS score, with subjects with greater depression at baseline (EPDS > 13) in the intervention group having a significantly lower postbaseline EPDS score compared with the usual care group (mean difference 4.06 points, 95%CI 1.51-6.61, p < 0.001). After adjusting for baseline HAM-D, subjects in the intervention group had a significantly lower HAM-D score at post-treatment compared with subjects in the usual care group (mean difference 1.83 points, 95%CI 0.24-3.41, p = 0.02). The difference in HAM-D became non-significant at 3-months post-treatment. CONCLUSIONS: Home-based exercise is a feasible nonpharmacological intervention with the potential to alleviate postpartum depressive symptoms, especially in women with higher initial depressed mood scores as measured by the EPDS. These findings may guide the design of future exercise clinical trials with postpartum depressed women.

Effects of home-based exercise on fatigue in postpartum depressed women: who is more likely to benefit and why?

OBJECTIVES: (1) To explore moderators of the effects of home-based exercise on reductions in physical and mental fatigue scores in postpartum depressed women and (2) to explore mediators of the intervention on changes in physical fatigue. METHOD: Eighty-eight women in the postpartum period (4-38 weeks) obtaining a score >or=10 on the Edinburgh Postnatal Depression Scale were randomly assigned to a 12-week individualized home-based exercise intervention (n=46) or a no-treatment control group (n=42). The present analyses include the 35 women who adhered to the intervention and the no-treatment control group. Participants completed a cardiovascular fitness test, and a battery of questionnaires assessing the outcomes (Physical and Mental Fatigue) as well as potential moderators and mediators at baseline and posttreatment. RESULTS: Hierarchical linear regressions evaluating moderators of changes in mental fatigue with exercise showed that the intervention was effective for women entering the study later in the postpartum period (P=.001) and women with higher depression scores (P=.014). Reductions in physical fatigue with exercise were partially mediated by reductions in perceived stress and increased exercise-related energy expenditure. CONCLUSION: Identification of moderators allows for the tailoring of exercise interventions to particular subgroups of women that are most likely to benefit. The identified mediators may be enhanced and directly tested in future trials.

Effects of a home-based exercise intervention on fatigue in postpartum depressed women: results of a randomized controlled trial.

BACKGROUND: Fatigue is prevalent during the postpartum period and may be heightened in postpartum depressed women. PURPOSE: To evaluate the efficacy of a home-based exercise intervention in reducing physical and mental fatigue scores in postpartum depressed women. METHODS: Eighty-eight women in the postpartum (4-38 weeks) obtaining a score > or =10 on the Edinburgh Postnatal Depression Scale (EPDS) were randomly assigned to a 12-week individualized home-based intervention (n = 46) or a control group (n = 42). All participants completed a cardiovascular fitness test at baseline. Outcomes were physical and mental fatigue scores and were measured at baseline, posttreatment and 3 months posttreatment. RESULTS: On the basis of intent-to-treat analyses, compared to the control group, women in the exercise group showed significantly greater reduction in physical fatigue at posttreatment [mean change = -4.07, (95% CI, (-5.15, -2.98)] and 3 months posttreatment [mean change = -4.24, (95% CI, (-5.36, -3.12)]. Significant reductions in mental fatigue with exercise were observed at posttreatment for women reporting lower physical fatigue at baseline. CONCLUSIONS: Fatigue is a common symptom experienced in the postpartum that can be heightened by depression. The findings show that home-based exercise can reduce physical and mental fatigue in postpartum depressed women.

Dimensions of fatigue in systemic lupus erythematosus: relationship to disease status and behavioral and psychosocial factors.

OBJECTIVE: To characterize the experience of fatigue in patients with systemic lupus erythematosus (SLE) using a multidimensional assessment and to delineate contributors to physical and mental dimensions of fatigue. METHODS: Fatigue in 130 women with SLE was assessed using the Multidimensional Fatigue Inventory (MFI-20). Participants completed standardized questionnaires assessing sleep quality, depressed mood, social support, and leisure-time physical activity. A clinical examination determined disease activity, cumulative damage, and whether patients fulfilled American College of Rheumatology criteria for fibromyalgia (FM). A series of hierarchical multiple regressions were computed to identify contributors to physical and mental fatigue. RESULTS: Patients scored high on all 5 MFI-20 fatigue dimensions, with general fatigue and physical fatigue having the highest scores. A hierarchical multiple regression showed that greater disease damage and disease activity, the presence of FM, depressed mood, sleep disturbance, and less participation in leisure-time physical activity contributed to higher physical fatigue scores. The results of the second model found depressed mood to be the strongest determinant of mental fatigue. Disease-related variables were not associated with mental fatigue. CONCLUSION: Fatigue in SLE is multidimensional and multidetermined, with physical and mental aspects likely having different etiologies. A multidimensional assessment of fatigue in SLE is needed to tailor and optimize interventions aimed at alleviating fatigue.

Adherence during an individualized home based 12-week exercise program in women with fibromyalgia.

OBJECTIVE: Treatment recommendations for fibromyalgia (FM) include regular physical exercise. In this prospective study we examined predictors for adherence to stretching and aerobic exercises in women provided with an individualized home based program. METHODS: Thirty-nine women kept exercise diaries for 12 weeks. RESULTS: For both types of exercise, women who were less physically fit at baseline engaged in more exercise during the program. Yet for stretching, more lower body pain at baseline predicted engaging in less stretching exercise over time, whereas for aerobic exercise, more baseline upper body pain predicted more exercise over time. As time passed, participants with higher baseline physical fitness and/or older age were reducing their aerobic exercise practice at significantly faster rates, as were those women with higher baseline stress. CONCLUSION: Given that adequate levels of adherence were limited to about half of the participants for both types of exercise, steps to reduce barriers to exercise (e.g., stress) need to be taken when prescribing exercise in the treatment of FM.

Maintenance of exercise in women with fibromyalgia.

OBJECTIVE: To identify predictors of maintenance of exercise for women with fibromyalgia (FM). METHODS: Women with FM who had been randomized to the exercise arm of a clinical trial were studied prospectively during and 3 months following treatment. Subjects completed exercise logs weekly and returned the data via postal mail. Outcome variables were duration of aerobic and stretching exercises. Two separate multivariate models for longitudinal data were built with adjustment for in-treatment adherence and time. Pretreatment characteristics (self efficacy, pain, disability, stress, exercise barriers and benefits, and age) and changes during treatment (pain, disability, stress, and exercise barriers and benefits) were considered potential predictors of exercise maintenance. RESULTS: Stretching significantly decreased in the 3 months following treatment. High stress at baseline and increases in stress during treatment were associated with poor maintenance of stretching. Disability at baseline (measured with the Fibromyalgia Impact Questionnaire), an increase in barriers to exercise during treatment, and increases in upper-body pain during treatment were associated with worse maintenance of aerobic exercise in the 3 months following treatment. CONCLUSION: The maintenance of an exercise program in women with FM appears to be contingent on being able to deal with stress, pain, barriers to exercise, and disability.

Determinants of sleep quality in women with systemic lupus erythematosus.

OBJECTIVE: To characterize sleep complaints in women with systemic lupus erythematosus (SLE) and to identify correlates of sleep quality. METHODS: Sleep quality in 100 women with SLE was assessed using the Pittsburgh Sleep Quality Index (PSQI). Participants completed standardized questionnaires assessing depressed mood, leisure time physical activity, functional disability, and pain severity. A clinical examination determined disease activity, cumulative damage, and whether patients fulfilled the American College of Rheumatology criteria for fibromyalgia. A series of hierarchical multiple regressions were computed. RESULTS: The mean +/- SD global PSQI score was 6.98 +/- 4.03, with moderate to severe sleep impairment reported by 56% of the sample. The first model testing the importance of demographic factors was not statistically significant. In the disease-related model, the use of prednisone and functional disability both contributed to poor sleep quality (P < 0.001). The addition of level of exercise participation to the demographic set significantly added to the model (P = 0.001). Depression significantly added to the demographic set, explaining 29% of the variance (P < 0.0001). When these variables, along with disease related variables, were simultaneously regressed on the PSQI Global Score, only depressed mood appeared as a significant independent determinant of global sleep quality (P < 0.001). However, the point estimates for the Beta coefficients were consistent with effects for lack of exercise and prednisone use. CONCLUSION: A significant proportion of women with SLE suffer from poor sleep quality. The findings suggest that depressed mood, prednisone use, and lack of exercise contribute to decreased overall sleep quality.

Mental health status and leisure-time physical activity contribute to fatigue intensity in patients with spondylarthropathy.

OBJECTIVE: To examine the relationship between disease-related variables, leisure-time physical activity (LTPA), and mental health status with fatigue severity in patients with spondylarthropathy (SpA). METHODS: Sixty-six SpA patients completed questionnaires assessing disease activity (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]), functional ability (Bath Ankylosing Spondylitis Functional Index), and health-related quality of life (Short Form 36). LTPA patterns, demographics, and disease-related data were obtained by interview. A clinical examination determined tender point count. Fatigue was assessed with the BASDAI fatigue item. RESULTS: The mean BASDAI fatigue score was 5.5 (SD=2.7) with 59% of the sample obtaining a score > or =5. Disease activity, functional disability, and worse mental health contributed to greater fatigue (R2=0.56). The relationship between exercise duration and fatigue intensity was moderated by mental health status. For patients with poorer mental health scores, exercise did not influence fatigue severity. However, for patients reporting better mental health status, engaging in more LTPA decreased fatigue severity. CONCLUSION: In addition to increased disease activity and functional disability, greater fatigue severity in SpA is associated with poorer mental health status. Integrating regular leisure physical activity into the comprehensive treatment of SpA may be useful for modulating fatigue.

Leisure-time physical activity patterns and relationship to generalized distress among Canadians with arthritis or rheumatism.

OBJECTIVE: Little is known about the epidemiology and possible mental health benefits of leisure-time physical activity (LTPA) for persons with arthritis and other rheumatic conditions. We examined the prevalence of LTPA and its association to generalized distress among Canadians with rheumatic conditions. METHODS: The 1996-97 National Population Health Survey interview data from respondents with rheumatic conditions (n = 10,700) and persons with no chronic conditions (n = 19791) in the same age range (20-79 yrs) were selected for analyses. Self-reported data on forms and frequency of LTPA engaged in over the past 3 months were collected. Intensity of LTPA was expressed as total energy expenditure, with respondents classified as Active (> or = 3.0 kcal/kg/day), Moderate (1.5-2.9 kcal/kg/day), and Inactive (< 1.5 kcal/kg/day). Generalized distress was assessed using a subset of items from the Composite International Diagnostic Interview. RESULTS: Similar to persons with no chronic conditions, roughly 56% of persons with rheumatic conditions engaged in regular LTPA (12 or more 15-minute sessions per month). Only 13.2% of women and 18.9% of men with rheumatic conditions were sufficiently active at the level recommended to yield optimal health benefits. Both moderate and higher intensity LTPA was associated with less generalized distress. This relationship was more pronounced for women and for middle-aged and older patients with rheumatic conditions. CONCLUSION: A significant proportion of Canadians with rheumatic conditions are physically inactive. Even moderate intensity LTPA is associated with decreased generalized distress. Better efforts must be directed at promoting LTPA as part of the multidisciplinary management of this condition.

Group psychotherapy reduces illness intrusiveness in systemic lupus erythematosus.

OBJECTIVE: We investigated whether brief supportive-expressive group psychotherapy might reduce illness-induced interference with valued activities and interests (i.e., illness intrusiveness) among women with systemic lupus erythematosus (SLE) in relation to 3 life domains: (1) relationships and personal development (family relationships, other social relationships, self-expression), (2) intimacy (relationship with spouse, sex life), and/or (3) instrumental life (work, finances, active recreation). METHODS: Women with SLE recruited from 9 rheumatology centers were randomly assigned to receive either usual care (n = 66) or a 12 week brief supportive-expressive group psychotherapy followed by 3 monthly booster sessions (n = 58). Standard instruments assessed disease activity and damage, illness intrusiveness, and psychological distress at 4 measurement occasions: (1) pretreatment, (2) posttreatment, (3) 6 month followup, and (4) 12 month followup. RESULTS: Analysis of covariance, controlling for disease activity and household income, indicated that women who received brief supportive-expressive group psychotherapy experienced significant reductions in illness intrusiveness for 2 of 3 domains: (1) relationships and personal development and (2) intimacy. Benefits were evident at 6 and 12 month followups. CONCLUSION: Brief supportive-expressive group psychotherapy facilitates adaptation to SLE by assisting women in reducing illness-induced disruptions into important domains of life experience.