Depression and anxiety can limit ability to care for one’s self, limit ability to care for a new baby or developing fetus, and can cause mood swings, impaired concentration, and sleep disturbance. Disorders of depression and anxiety are common in the perinatal period (immediately before and after birth) with depression rates around 20% and perinatal anxiety present in about 10% of women. These mood disorders greatly diminish quality of life for mother and baby. Medication may be effective, however, side effects are often unknown, and potentially adverse for the perinatal patient. Many women worry that using medication to treat these disorders may harm the fetus, negatively affect mother child bonding, and poorly influence child development. As health care providers, being aware of alternative treatments for depression and anxiety is essential. Having alternative treatments can allow our patients to combat these common perinatal problems which will improve quality of life, improve bonding between baby and mother and improve the overall perinatal experience. In the general population, positive mental and physical health benefits have been continually demonstrated by yoga participants in current research. Can yoga be an effective, alternative treatment to help perinatal patients improve mental health and well-being?
A recent 2015 systematic literature review published in the Journal of Holistic Nursing reviewed 13 studies to examine existing empirical literature on yoga interventions and yoga’s effects on pregnant women’s health and well-being. The conclusion of the review found that yoga interventions were generally effective at reducing depression and anxiety in perinatal women and the decrease in depression and anxiety was noted regardless of the type of outcome measure used and results were optimized when the study was 7 weeks or longer. Other positive secondary findings noted with the regular yoga participation in the perinatal participants were: improvements in pain, anger, stress, gestational age at birth, birth weight, maternal-infant attachment, power, optimism, and well-being. What is yoga and what form of it may help battle perinatal depression and anxiety?
Yoga by definition is a Hindu philosophy that teaches a person to experience inner peace by controlling the mind and body. Merriam-Webster defines yoga as a system of exercises for attaining bodily or mental control and well-being. All styles of yoga include some combination of physical poses, breathing techniques, and meditation-relaxation techniques. Hatha yoga is the most common form completed in the United States and consists modernly of various postures, breathing, and meditation. In the 13 reviewed studies, all interventions consisted of different forms of yoga and the overall conclusion of the systematic review was the decrease in depression and anxiety was significant no matter the form of yoga completed. Physical and emotional issues such as hormonal changes, sleep deprivation, inability to handle new tasks, self-worth, and body issues, during the perinatal period can contribute to increased anxiety and depression. As health care providers we need to have alternative treatments to help our perinatal patients’ battle depression and anxiety. Yoga is a promising alternative to medication to help decrease depression and anxiety. Additionally it may be helpful for management of pain, anger, stress, gestational age at birth, birth weight, maternal-infant attachment, power, optimism, and well-being.
Interested in learning more about how you can apply therapeutic yoga in your practice? Check out "Yoga as Medicine for Pregnancy this April in Washington, DC!
Sheffield, K. M., & Woods-Giscombé, C. L. (2015). Efficacy, Feasibility, and Acceptability of Perinatal Yoga on Women’s Mental Health and Well-Being A Systematic Literature Review. Journal of Holistic Nursing, 0898010115577976.
A recent literature review addressing the effectiveness of yoga for depression reports that the positive findings are promising. The 2007 National Health Interview Survey (NHIS) found that yoga was one of the top 10 complementary health approaches used among adults in the United States. (The linked page for the NHIS also includes a video of the scientific results of yoga for health.)
Yoga is not only about bodies bending- ancient yoga traditions offer physical, mental, and spiritual techniques that are designed to be holistic in nature. Many instructors in the US focus on the many physical benefits of yoga, yet there are many types of yoga, many instructors with varied levels of training, and many health issues that require an individualized program of yoga therapy. In relation to the potential effects of yoga on depressive symptoms, theories in neurobiology point to the potential positive effects on the HPA (hypothalamic-pituitary-adrenal) axis, according to the linked article by Lila Louie.
While none of the articles described in the literature review are specific to the one patient group or population, the subjects studied include incarcerated women, older patients, university students, and patients from the general population who struggle with depression. One group of patients known to be at risk for severe depression is postpartum women. The definition of postpartum varies, and a generous definition may include any issue that, once imparted in a postpartum period and left unaddressed, could persist throughout a woman's lifetime. This is commonly seen in the clinic as uncorrected postural dysfunction, pelvic floor dysfunction, or gait changes, for example.
Because both yoga and exercise "appear to ameliorate depression," the author of the literature review states that motivation and compliance towards either modality should be considered during treatment planning for patients. Louie further states that yoga practice of asanas is safe, cost-effective, versatile, and can be used on its own or as an adjunct to medication. If you would like to learn more about the use of yoga for the postpartum population, sign up for Ginger Garner's continuing education course: Yoga as Medicine for Labor and Delivery and Postpartum offered in Seattle in August. To read about Ginger's Yoga as Medicine for Pregnancy course, click here.
In our blog, we have highlighted the importance of recognizing and screening for postpartum depression. What relationships exist between a person's posture and depression in the postpartum period? Prior research reporting on four studies of posture (Riskind & Gotay, 1982) noted that subjects placed in a slumped physical posture appeared to develop helplessness more easily than those placed in an upright posture. These authors also stated that physical posture was a valuable clue for an observer who attempted to identify states of depression. Results of the fourth study include that "…subjects who were placed in a hunched, threatened physical posture verbally reported self-perceptions of greater stress than subjects who were placed in a relaxed position."
A recent study addressed depression, back pain and postural alignment in eighty women between 2 and 30 weeks postpartum. Depressive symptoms were measured with the Edinburgh Postnatal Depression Scale (EPDS). Pain scales included a visual analog scale (VAS) and the Nordic Musculoskeletal Questionnaire (NMQ while posture was assessed with visual observation. Findings of the study include that VAS pain scores were elevated in the women who were depressed. Back pain intensity and postpartum depression were also strongly associated. The authors suggest that back pain may be a risk factor for postpartum depression as well as a comorbidity. The article further states that physical therapists "…should be prepared to identify depressive symptoms as a comorbidity associated with posture changes and recurrent symptoms, signs of remission and recurrence that generate difficulties for treatment progression."
Can we look at this issue as a chicken and egg discussion, as in, is poor posture causativeto depression, or vice versa? And,if smiling has been determined to have the ability to improve happiness, can improved posture positively affect symptoms of depression? We know that postural dysfunction and pain can be a vicious cycle in our patients. Is screening for depression an equally important aspect of postural correction? Could postural taping, support, or re-training positively affect postpartum depression, and if so, should we be assessing and re-assessing our patients for depression as a means to document therapy benefits? The fun thing about reading research results is that the studies often lead to more questions, further hypotheses, and curiosity in relationship to how we interact with our patients. Can patients understand the relationship between postural correction and emotional health? Sounds like an opportunity for more research, and for dialoging with our patients!
If you are interested in learning more about postpartum health, click here for more information about the second course in our Peripartum series, Care of the Postpartum Patient. The next opportunities to take this class are June in Houston, and Chicago in September!
A recent article titled "Pain, Catastrophizing, and Depression in Chronic Prostatitis/Chronic Pelvic Pain Syndrome" describes the variations in patient symptom report and perception of the condition. The article describes the evidence-based links between chronic pelvic pain and anxiety, depression, and stress, and highlights the important role that coping mechanisms have in reported pain and quality of life levels. One of the ways in which a provider can assist in patient perception of health or lack thereof is to provide current information about the condition, instruct the patient in pathways for healing, and provide specific care that aims to alleviate concurrent neuromusculoskeletal dysfunction.
Most pelvic rehabilitation providers will have graduated from training without being informed about chronic pelvic pain syndromes. And as most pelvic rehabilitation providers receive their pelvic health knowledge from continuing education courses, unless a therapist has attended coursework specifically about male patients, the awareness of male pelvic dysfunctions remains low. If you are interested in learning about male pelvic health issues, the Institute introduces participants to male pelvic health in the Level 2A series course. The practitioner who would like more information about male patients can attend the Male Pelvic Floor Function, Dysfunction, and Treatment course that is offered in Torrance, CA at the end of this month.
The authors in this study point out that chronic pelvic pain is not a disease, but rather is a symptom complex. Despite the persistent attempts to identify a specific pathogen as the cause of prostatitis-like pain, this article states that "…no postulated molecular mechanism explains the symptoms…" As with any other chronic pain condition, research in pain sciences tells us that behavioral tendencies such as catastrophizing is not associated with improved health. The authors utilized a psychotherapy model in developing a cognitive-behavioral symptom management approach and found significant reductions in CPP symptoms. The relevance of this information for our patient population includes having the ability to screen our patients for depression, to recognize tendencies to catastrophize, and to implement useful strategies for our patient.
What does your facility currently use as a depression screening tool? Having this information at hand when communicating with a referring provider is very helpful. Explaining the biology of the vicious cycle of emotional stress and pain responses can help a patient understand why following up on a referral to a psychologist or counselor may be helpful towards his health. Identifying catastrophizing as the patient who is hypervigilent about symptoms, ruminates about his condition, expresses an attitude of helplessness, or magnifies the threat of the perceived pain can aid in identification of the patient who needs more than a few stretches, a TENS unit, or manual therapy.
A new course offered this year by the Institute will provide excellent foundational background information as well as practical patient care techniques about emotional and psychological principles that influence chronic pain. This course, Integrating Meditation and Neuropsych Principles to Maximize Physical Therapy Interventions, is instructed by Nari Clemons, a physical therapist who excels in pelvic rehabilitation, and Shawn Sidhu, a psychiatrist with a special interest in mind body medicine. The course is offered only one time this year, in September in Illinois, so sign up early!
Wendy Sword, Professor in the School of Nursing at McMaster University, and her colleagues have recently published a study in which they looked at the relationship between mode of delivery and risk for post-partum depression. An interesting correlation that the authors found shows that having urinary incontinence in the first 6 weeks after childbirth doubles the risk for having post-partum depression. In McMaster University's post about this research, it is pointed out that up to 20% of new mothers experience post-partum depression, and this can interfere with the mother's self-care, with bonding between the mother and child, and with the care needed by the infant. Early detection and treatment of post-partum depression is critical.
In this research, 1900 new mothers were studied, up to 1/3 of them had c-sections as the mode of delivery. At 6 weeks post-partum, nearly 8% of the mothers had post-partum depression. The depression was not identified as being related to one mode of child delivery over another. The 5 strongest predictors of post-partum depression were identified as: 1) mother's age less than 25, 2) mother requiring hospital readmission, 3) non-initiation of breast-feeding, 4) good, fair, or poor self-reported health by the mother, and 5) urinary incontinence.
Dr. Sword recommends that providers ask patients about continence status early in the post-partum period, as patients may be embarrassed to bring it up, and also because incontinence is often dismissed as a common issue post-partum that will likely improve. When patients are referred to rehabilitation for continence issues, we often find that the symptoms have persisted for years, sometimes decades, unfortunately. During our marketing visits and education of the community, we can also encourage patient providers to send the patients to rehabilitation as early as possible. It is often at the 6 week appointment that the patient can be screened for such concerns, and this is when many of our referrers are comfortable sending a patient in for a check of the pelvic muscles.