Men's health is an important public health issue (Baker et al, 2014). Over the past 3 decades, the issue of men's health has moved from the margins to the centre of health discourse (Richardson, 2013). During this period, there has been a growing awareness and concern about the burden of ill health experienced by men (Department of Health and Children, 2008). Men's health has the potential to be influenced by the transition to fatherhood. Becoming a father, for many men, signals a shift away from individualism and leads to an increasing sense of personal responsibility and self-reflection that initiates positive behaviour changes (Garfield et al, 2010). Research has shown that fatherhood has a protective effect on men's health (Markey et al, 2005; Garfield et al, 2010). Notably, chronic pain, insomnia, gastrointestinal problems and fatigue are less problematic for fathers than for other male subsets of the population, and fathers have a lower risk of dying from cardiovascular disease (Eisenberg et al, 2011). However, there is also evidence that the transition to fatherhood can be complex and demanding, and may have a negative impact on men's health (Kim and Swain, 2007; Lara et al, 2010; Sheng et al, 2010).
Transition to fatherhood
The transition and adaptation to fatherhood is considered one of the most acute changes experienced during a man's life (Wilson, 2008). The experience is influenced by personal, infant and environmental factors (Wilkins, 2006; Salonen et al, 2009). Aside from the many joys, the postnatal period is marked by significant change and the absence of routine (Wilson, 2008). Fathers experience many of the same changes and stresses that mothers do, such as sleep disturbance, fatigue, relationship strain and financial worries (McCoy, 2012). While some fathers anticipate that they may find it difficult to adapt to parenthood, many fathers are not fully aware of the impact a baby will have on their lives (McKellar et al, 2009).
In recent decades, unprecedented social change has seen a great shift in the role of fathers. The traditional roles that define men's relationships within families have undergone a number of changes. This has resulted in an expectation that men play an equal and direct role in caring for their children (Veskrna, 2010). However, a number of fathers may not have had a role model from whom to learn appropriate fathering skills, having grown up during a time when men were either uninvolved or minimally involved in child-rearing (Condon et al, 2004). Some fathers may have grown up in single-parent families where their mother had to cope alone; this may result in some men feeling inadequate and ill-equipped as they begin their journey into fatherhood. This can cause distress, anxiety and increased risk of depression (Veskrna, 2010).
Postnatal depression
Postnatal depression (PND) is a non-psychotic depressive disorder that occurs after the birth of a child (Massoudi, 2013). It has typically been associated with women—it was perceived as a product of hormonal changes and, consequently, most of the research focused on women (Buist et al, 2003, Kim and Swain, 2007; Wee et al, 2011). However, researchers now acknowledge that PND is also the product of psychosocial causes. It can, therefore, be presumed that such factors would also have an impact on the mental health of involved fathers in the postnatal period (Wilson, 2008).
Paternal postnatal depression (PPND) is not widely acknowledged, nor is it well researched. In general, the mental health of fathers in the postnatal period is often not considered. This has resulted in men being underscreened, underdiagnosed and undertreated for PPND and other postnatal mental health problems (Musser et al, 2013). The study of PPND is still in its infancy. However, an understanding of the problem has advanced considerably over the last 10 years (Wee et al, 2011; Philpott and Corcoran, 2014).
Definition and prevalence of paternal postnatal depression
There is currently no specific definition for PPND. Most studies use the definition for maternal postnatal depression (MPND) to build on for defining PPND. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (American Psychiatric Association, 2013: 187), MPND is an ‘episode of major depression if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery’. The onset limitation of 4 weeks has been criticised in the literature as it does not reflect the epidemiological evidence. In both clinical practice and research, it is common to use the term PND when referring to depressive episodes occurring in the first 12 months postpartum (Wisner et al, 2010). The 12-month timeframe is chosen because this is the period of most significant change and readjustment in family and work life.
Estimates of the prevalence of PPND within the first year vary widely, ranging from 1% to 27% (Lane et al, 1997; Bielawska-Batorowicz and Kossakowska-Petrycka, 2006). The wide statistical variation of estimates is related to the fact that different measurement tools are employed across studies. A review of 43 studies found that PPND affects up to 10% of new fathers throughout the world (Paulson and Bazemore, 2010). However, the prevalence may be even higher, as men are believed to be reluctant to report mental health problems.
Risk factors for paternal postnatal depression
Many factors have been identified in the literature as contributing to PPND; however, the direction of causality is not always clear.
Maternal depression
Maternal depression has been reported as the most common predictor for PPND (Kim and Swain, 2007; Wilson, 2008; Wee et al, 2011). Depression in one partner is significantly correlated with depression in the other. Fathers are more likely to be depressed if their partner is experiencing PND (Goodman, 2008; Wilson, 2008). While the causal relationship for this is unclear, it has been suggested that male partners of depressed women experience helplessness, confusion, frustration and uncertainty about the future (Schumacher et al, 2008).
Social support, family factors and unintended pregnancy
Fathers in traditional marital relationships, i.e. in their first marriage and living with their children, have a lower prevalence of PPND, while men living in stepfamilies are at an increased risk of depressive symptoms (Deater-Deckard et al, 1998; Schumacher et al, 2008; Wee et al, 2011). Higher levels of social support are associated with reduced rates of PPND, while a poor relationship is correlated with an augmented risk of PPND (Schumacher et al, 2008; Philpott and Corcoran, 2014). Fathers who experience more challenges with childcare than initially expected report higher levels of PPND (Philpott and Corcoran, 2014). An unplanned pregnancy is significantly associated with depression in fathers. A lack of choice and preparation inherent in unplanned pregnancies increases the risk of PPND (Oladosu, 2012).
Education and information
Lower levels of education are associated with higher levels of PPND (Boyce et al, 2007; Philpott and Corcoran, 2014). Fathers who are less well-educated may experience greater difficulty in gaining information about and access to services in the perinatal period. This subsequently results in these men being less informed and less prepared for the changes that an infant brings (Oladosu, 2012).
Age
A British study reported that fathers over 30 years old were significantly less likely to experience PPND symptoms than younger fathers (Ballard et al, 1994). These findings were reflected in a small Polish study, which reported that depressed fathers were significantly younger than non-depressed fathers (Bielawska-Batorowicz and Kossakowska-Petrycka, 2006).
History of psychiatric disorder
A previous history of psychiatric disorder was strongly linked to the development of PPND in a Japanese study (Nishimura and Ohashi, 2010). Compared with other mental health disorders, depression poses the most significant risk for developing PPND (Wee et al, 2011). This may be due to predisposing genetic factors and/or enduring environmental factors, with the perinatal period acting as a stressful life event that triggers a recurrence (Oladosu, 2012).
Manifestation of paternal postnatal depression
PND in women is characterised by low, sad mood, lack of interest, anxiety, sleep disturbance, reduced self-esteem and difficulty coping with day-to-day tasks (Cox and Holden, 2003). PND in men manifests itself differently, and includes such symptoms as hostility, conflict and anger. In addition, men also tend to engage in escape activities such as overwork, sports, sex, gambling and alcohol abuse (Veskrna, 2010). In the general population and during the postnatal period, women tend to internalise distress while men tend to externalise it through aggressive or coercive behaviour (Box 1). As a result, more women are diagnosed with depression and anxiety (or internalising disorders) while more men tend to self-harm and have higher levels of substance abuse and antisocial disorders (or externalising disorders) (Eaton et al, 2012).
| Anger attacks |
| Affective rigidity (failure to express emotions) |
| Self-criticism |
| Alcohol and drug abuse |
| Unhealthy sexual relationships or infidelity |
| Reckless behaviour, such as unsafe driving |
| Abusive behaviour |
| Escapist behaviour, such as spending excessive time watching TV, on the internet or at work |
Impact of paternal postnatal depression
Apart from the detrimental effects that PPND can have on a father's health, there are numerous potential negative effects on the health and wellbeing of the mother and child.
Impact on maternal and child outcomes
Approximately half of all fathers with PPND have partners with MPND (Goodman, 2004). The support of a partner has been established as a protective factor against PND. Low levels of support from fathers who experience PPND may cause a mother to become more vulnerable to stress and psychopathology. This may be further compounded by the symptoms of the male depressive syndrome such as aggression/violence and alcohol and/or drug abuse (McCoy, 2012; Massoudi, 2013).
Depressed fathers display fewer positive behaviours such as sensitivity, warmth and responsiveness, and increased negative behaviours such as hostility and disengagement. Paternal behaviours may be directly related to the psychological symptoms of depression, such as fatigue and anhedonia (an inability to feel pleasure in normally pleasurable activities), which may lead to irresponsiveness, while irritability may cause increased hostility (Wilson and Durbin, 2010). Overall, research concerning the effects of PPND on infant and child development and wellbeing has reported a higher risk for increased family stress, lack of bonding, increased incidence of spanking, and later child psychopathology such as emotional issues, conduct disorder, and hyperactivity (Ramchandani et al, 2008; Ramchandani et al, 2013).
Intervention and management
Screening for paternal postnatal depression
There is no evidence that screening for PPND occurs, despite the existence of research highlighting the importance of screening, especially where MPND has been diagnosed (Goodman, 2004). Furthermore, there is no screening tool specifically designed for PPND. However, the Edinburgh Postnatal Depression Scale (EPDS), which was developed to screen for MPND, has been validated for use with fathers (Massoudi, 2013). The EPDS is the most commonly used screening tool in PPND studies. While there is a lack of research in relation to the most suitable opportunities to screen and educate fathers in relation to PPND, antenatal classes, the birth period during their partner's hospital stay, and the postnatal period during home visits, are all potential opportunities when midwives may be in contact with fathers (Box 2).
| Antenatal period: classes and clinics |
| Verbal discussion |
| Posters in clinical areas |
| Assess/screen for risk factors |
| Birth period: during hospital stay |
| Assess/screen for risk factors |
| Verbal discussion |
| Anticipatory guidance in discharge instructions |
| Printed material for reading at home |
| Postnatal period: home visit/child welfare clinics |
| Assess/screen for risk factors |
| Verbal discussion |
| Printed material for reading at home |
| Posters in clinical areas |
Diagnosis
There is no official set of diagnostic criteria for PPND. There are diagnosis criteria for women outlined in the Diagnostic and Statistical Manual of Mental Disorders. The validation of diagnosis criteria for PPND and the development of a screening tool is crucial, as there are differences in the risk factors for and the course (timing of onset, persistence) of PND for fathers and mothers. For example, there are findings suggesting that PPND develops more slowly and gradually over the more protracted course of a full year (Kim and Swain, 2007). Thus, the diagnostic criterion outlined for women of an onset within 1 month postpartum may not be appropriate for diagnosing men.
Management and intervention
Support from family members helps fathers adapt to changes during the postpartum period. PPND is closely related to partners' mental health and the health of the relationship. Therefore, the most effective support for men comes from their partner. For example, mothers sharing parenting roles with fathers may lower fathers' feelings of isolation from the relationship between mother and infant, as well as difficult feelings such as jealousy toward the infant. Support and acknowledgement from other family members about the father's role and understanding the difficulties the fathers may encounter can also have a positive effect on fathers (Kim and Swain, 2007; Philpott and Corcoran, 2014).
Support from society, such as paid paternity leave, helps fathers adapt to changes during the postnatal period. Paternity leave is designed to increase father involvement by allowing men to be absent from work for a certain period of time commencing with the birth of their child (O'Brien, 2009). Paternity leave has been identified as one of the few policy tools available to governments to directly influence behaviour among fathers (Organization for Economic Cooperation and Development (OECD), 2011; Radcliffe and Cassell, 2015). It is also one of the strongest public statements that societies can make to show that they value the care work of men (United Nations, 2011; Ugreninov, 2013).
The Nordic countries were the first to introduce paternity leave to encourage men's participation in the care of their children; today, Nordic men are known for their involvement in childcare (Wall and Escobedo, 2013; Romero-Balsas, 2015). Research from the Nordic countries highlights the benefits of proactive father involvement policies. Studies have highlighted the fact that fathers taking paternity leave is associated with: higher levels of contact with children should the mother and father subsequently separate (Duvander and Johansson, 2012); adoption of healthier lifestyles (Månsdotter et al, 2007); and decreased risk of all-cause mortality (Månsdotter and Lundin, 2010). A lack of paternity leave is associated with low-quality childcare, less adaptation at work among fathers, and PPND (Feldman et al, 2004; Kim and Swain, 2007; Philpott and Corcoran, 2014).
Lack of understanding and supportive net works for fathers is common. Traditionally, fathers have played a supporting role for their partners postnatally. However, given the increase in fathers' involvement in parenting, support that focuses on the active roles of fathers is needed to help new fathers ease their stress in the early postpartum period (Kim and Swain, 2007). Strategies that have been used for women include increased contact with health professionals and support groups. These prevention-management strategies could be implemented for fathers, especially those whose depression is compounded by a lack of social support. However, further research is needed to establish what type of strategies and interventions prevent PPND (McKellar et al, 2009; Gawlik et al, 2014).
Strategies midwives can implement
Midwives are well-positioned to initiate screening and outreach programmes for new fathers and to advocate for the inclusion of information about PPND into existing programmes.
While few interventions have been rigorously evaluated, from the available research it is known that the most significant risk factor for PPND is MPND. Therefore, when an expectant or new mother is depressed or has developed a psychiatric problem, an assessment of her partner's mental health and general wellbeing should be undertaken.
Research has highlighted that many men are not aware of PPND. In an Irish study, 74% of the fathers surveyed were not aware that PPND existed (Philpott and Corcoran, 2014). Midwives working in all clinical areas can increase awareness about PPND among fathers and their partners. Couples who have been educated about the signs and symptoms of PPND are more likely to be aware and alert if, or when, the problem occurs. This knowledge will enable men to ask for help and seek out the necessary resources for their care.
Midwives are ideally placed to inform fathers and their partners about the resources available in their local area and online, should they have a concern or enquire about PPND (Box 3).
| The National Childbirth Trust (NCT) offers online support for fathers and shared experiences |
| The charity Mind offers a postcode search to find local support |
| The Depression Alliance is a charity that supports a network of self-help groups in England, Action on Depression offers self-help groups in Scotland, and the charity Journeys offers peer support groups in Wales |
| The BabyCentre community offers online support for fathers |
| The Samaritans offers 24-hour support from trained volunteers |
| DadsMatterUK raises awareness of the impact of perinatal mental health and highlights that ‘dads matter’ too |
| Sane is an organisation with lists of local support resources that can help with depression and other psychological problems |
| The NHS website explains how depression is treated on the NHS and where to find help locally |
Conclusion
Despite the evidence that fatherhood has a long-term positive and protective effect on men's health, there is also evidence that the transition to fatherhood can be complex and demanding. The postnatal period is marked by significant change and the absence of routine. While most of these changes are expected and welcome, others can be unanticipated and have a negative impact on the health of fathers. Fathers experience many of the same changes and stresses that mothers do, such as sleep disturbance, fatigue, relationship strain and financial worries. A number of fathers may not have had a role model from whom to learn appropriate fathering skills, having grown up in a time when men were either uninvolved or minimally involved in child-rearing. This has resulted in some men feeling inadequate and ill-equipped as they begin their journey into fatherhood, which can subsequently cause distress, anxiety and increased risk of depression.
With a prevalence of approximately 10%, PPND is a real and significant public health issue. However, it is not widely acknowledged and there is a dearth of research. Men are underscreened, underdiagnosed and undertreated for PPND and other postnatal mental health problems. Midwives are well-placed to provide information to couples about the potential effects of the transition to parenthood on mental health, and direct fathers to resources and support if necessary.