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Paternal perinatal depression: It's time we brought fathers into the perinatal agenda

‘With the elation came a significant adjustment to the novel, demanding and various roles that accompanied the arrival of Olive’. In Joe’s blog published yesterday, he shares his experience of becoming a new dad.

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I am a Lecturer in Psychiatry and Mental Health (Education) at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London (KCL). My academic career in the early life course, involves looking at the interconnections between biology, psychology, and socio-environmental processes linking perinatal mental health to children’s development. In particular, my research focuses on the role of fathers (their influence on maternal health and child outcomes) in the early parenting environment.


A Major Life-Altering Moment for Men

During the period of transition to fatherhood, many new dads may engage in self-reflection to positively modify their own health behaviours — often triggered by a feeling of intense responsibility, and the identification of being a role model for their baby. While some fathers adjust to their new role, it is increasingly common for others to find it difficult to cope with the demands of family and work life. This may leave some first-time dads feeling overwhelmed and particularly vulnerable to mental health difficulties.

Joe recalls experiencing periods of low mood and anxiety symptoms since he was a teenager; his partner's pregnancy and the arrival of their baby (a stressful life event) triggered a relapse of his symptoms.

Research has shown that in the postnatal period, depression rates are double that of the general population of men. Studies that consider the mental health of fathers report that when one parent experiences emotional difficulties their partner may also struggle with mental health problems. Low mood experienced by fathers in the first six months after birth, may have an influence on their partner's emotional well-being. Thus, placing their child’s health at risk.

Hence, shouldn’t fathers be included in perinatal health?

Joe emphasises, that generally when fathers are in good health, they can provide the necessary support mothers may need, and positively influence their child’s healthy development.

Indeed, evidence supports this idea — for instance, emotional support from fathers helps mother’s to cope with their fatigue and childcare tasks, bond with their babies, in turn promoting their child’s wellbeing. Furthermore, fathers independently promote their children’s development in early life. Paternal sensitivity (the ability of the father to correctly interpret and respond appropriately to their infant or child’s signals) and engagement as early as 3-months influences children’s cognitive skills.

Yet, some men may have trouble admitting that they feel depressed even to themselves, and society expects men to ‘man up’ during this period of increased emotional and financial burden. Justifiably, the focus and development of services is on the mother and new baby, and traditionally the mental health of fathers in the perinatal period has received less attention. But is manning up really a part of the answer?

Our discussion turns to 2006.

A developing interest in the role of the family in early child development, set me on a three-year journey to learn more about postnatal depression in fathers. During this time, there were various instances when I was asked what my PhD research involved — and often my enthusiastic response was promptly tweaked, ‘So, do you mean postnatal depression in mothers’?

Paternal Postnatal Depression: It’s real!

Since then, updated meta-analytic evidence (obtained by merging the findings from 74 independent studies) has indicated that approximately 8 out of every 100 fathers globally, experience depression during pregnancy and until 12 months after birth. The prevalence of paternal postnatal depression (PPND) being much higher — between 24% and 50% — in men whose partners suffer from postnatal depression. Like mothers, depressive symptoms occur from the start of pregnancy in fathers and can continue to two years after childbirth. Thus, PPND justifies early (pre-conception, i.e., before pregnancy) detection and appropriate support efforts.

Notably, there are no official criteria to make a diagnosis of PPND. Mental health conditions are diagnosed using a guide. One such guide is the Diagnostic and Statistical Manual of Mental Disorders (Fifth edition) also known as DSM-5. Maternal postnatal depression is diagnosed using DSM-5 (covering depressive episodes occurring during pregnancy, as well as in the four weeks following delivery).

Fathers also tend to show symptoms such as anger attacks and an increase in alcohol use and video gaming, not often recognised in the diagnosis of maternal postnatal depression. Others may escape from the family, overworking or indulging in excessive sport. Hence, a diagnosis should include a broader range of symptoms beyond those covered by the criteria used for mothers.

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Screening tools (short questionnaires) can be used to support the diagnosis. So far, the most widely used self-report questionnaire in fathers is the Edinburgh Postnatal Depression Scale (EPDS). This scale was originally developed for mothers and screens for depression and anxiety symptoms. Since men are less expressive about their feelings than women, they would likely score lower on depressive and anxious symptoms — yet experience the same level of distress as mothers. Another more recent tool is the Perinatal Assessment of Paternal Affectivity (PAPA), which does consider some of the additional symptoms’ fathers may experience. The consideration of stress (which is a risk factor for PPND), has also been utilised. More work is needed in this area to identify a suitable screening tool for fathers.

Photo by Josh Willink on Pexels

Factors associated with PPND seem to be the same as those reported for mothers. A history of mental health difficulties (and specifically depression), coupled with a difficult childhood environment, may leave fathers vulnerable to depression in pregnancy and after the birth of their child.

Maternal depression has consistently been found to be the most important risk factor for depression in fathers during pregnancy and in the postnatal period. Couple conflict, lack of social support, high levels of stress in pregnancy, an unexpected pregnancy, and complications during pregnancy and birth, have also been linked with PPND. It is common for some of these risks to co-exist.

At this stage in our conversation, Joe and I recognise the many challenges to help-seeking by fathers.

On the personal level, some new fathers may experience stigma and self-blame, reduced awareness of their own symptoms and perceptions of mental health. Likewise, the availability of resources for fathers and family members, and communication with health professionals, potential challenges. High on the agenda, concerns about compromising the support available to women and the consequences of disclosing mental health problems.

I reflect on similar challenges reported by health professionals and services from our recent research study — ‘at the practitioner level (e.g., knowledge, skills, confidence, attitude and scope of practice, fear of causing offence) and at the service level (e.g., lack of onwards referral options, resources/workload issues (time pressures), and tools being unavailable in different languages)’.

A defining moment: Including fathers in the perinatal mental health agenda

Yet, Joe and I agree that this is a time of significant progress and insight for all involved.

Partnerships across parents/wider family members, academics, perinatal health professionals, voluntary/third sector, and peer support organisations, have helped in our understanding of PPND. Notably, mothers and fathers have played a significant role in this effort — sharing their own experiences, providing a safe space for speaking, and campaigning tirelessly not only for the awareness of PPND but for assessment recognition and support for fathers. This is also very much a global effort.

Currently, several services and organisations in England are engaged in tremendous work to support fathers with their own mental health, family relationships, their role in supporting mothers and their family, as they transition to parenthood. Some examples are available in a good practice guide, which was developed for commissioners and colleagues working to support women and their infants in specialist perinatal mental health services.

Photo by Josh Willink on Pexels

Our collective efforts are gradually translating to a change in policy. For instance, the National Health Service’s (NHS) long term plan aims to involve and support fathers and partners of women accessing services. They will be provided with an assessment for their own mental health and signposted to relevant support. Another example comes from Sweden where the shared parental leave reform will enable the involvement of fathers in childcare.

There is yet a long way to go. But as we conclude our conversation, it is very clear that the health and happiness of mothers, babies, and families, depends on the wellbeing of fathers. It is about time they are included in the perinatal agenda.


Editor's Note:

If you have enjoyed this blog, do not miss the full 10-part series that will explore aspects of modern-day fatherhood, men’s mental health, and the science behind it — running through to the 19th of November — which is also International Men’s Day UK.

As part of this series, please find our already published blogs including:

  • Our blog written by our Editor in Chief, Professor Carmine Pariante, where he interviews Elliott Rae, the founder of Music.Football.Fatherhood (MFF) and publisher of the book DAD.

  • A blog written by Arran Williams where he discusses the emotional impact his partner’s two traumatic birth experiences had on him.

  • A blog written by Clinical Psychologist, Jane Iles, in response to Arran’s blog, where Jane explores the impact traumatic births can have on fathers’ mental health from a clinical point of view.

  • The blog written by Joseph Straker, mentioned throughout this piece, where he discusses his own personal experiences of postnatal depression.

Every Wednesday we will publish a lived-experience piece from one of the fathers who have contributed to the recently published book DAD or the Music. Football. Fatherhood. (MFF) online platform, an online community of Fathers. This will be followed on the Thursday by a scientific piece from one of our contributing scientists exploring the associated mental health aspects.

We hope you enjoy this ITM special series as we shine a spotlight on men’s mental health and fatherhood.


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