Features

Silent sadness: the truth about paternal PND

Postnatal depression in fathers and the effects on childhood development need urgent attention as too many men are suffering in silence, says health visitor Helen Knapman.

Paternal PND

Postnatal depression (PND) is defined as a non-psychotic depressive illness of mild to moderate severity occurring during the first postnatal year (Royal College of Psychiatrists, 2015) and it has long been viewed as a female-specific condition. Much has been written about maternal PND and its effects on child development (Goodman, 2004). In stark contrast there is a lack of literature about both paternal PND and its effects on child health functioning (Dave et al, 2005).

Currently, there is no clinical definition or diagnostic criteria for paternal PND (Kim and Swain, 2007) and it is not a commonly recognised medical occurrence (Goodman, 2004). In fact, the recent NICE guidelines (2016) for antenatal and postnatal mental healthcare discuss the importance of supporting the father of a depressed spouse but provide no guidance on how to identify paternal postnatal depression, or how to best intervene. This lack of recognition can lead to an underestimation of prevalence and population need (Ramchandani et al, 2008).

Despite this, emerging statistics suggest 10.4% of fathers suffer with PND (Paulson and Bazemore, 2010). 

Furthermore, an alarming feature of paternal depression is the increased risk of suicide found in fathers with mood disorders during the postnatal period. Work by Quevedo et al (2011) indicates the incidence of suicide risk in the postnatal period for fathers with paternal PND was 4.8% higher compared with fathers without depression. The evidence also suggests that there is a correlation between paternal PND and detrimental cognitive, social-emotional, and behavioural outcomes for children (Dave et al, 2005).

The following findings, together with my conclusions and suggestions on how to improve the situation for fathers, are based on my dissertation. This was a literature review on paternal PND and the effects it may have on early child development (Knapman, 2014).
 

What’s behind paternal PND?

Some factors that contribute to maternal PND are the same for paternal PND; however, other factors are specific to fathers. This includes the impact of changing social roles for fathers in the family. Traditionally fathers have been ‘the bread winners’ who provide financial stability for their families. However, in contemporary society fathers are expected to cope with demands additional to providing financial support: fathers are also expected to play an active role in childcare and provide emotional support to their spouses, and it is suggested these increasing demands may impact negatively on fathers’ psychological wellbeing in the postnatal period (Halle et al, 2008; Bielawska-Batorowicz and Kossakowska-Petrycka, 2006). Other specific features include increased financial responsibilities, increased dissatisfaction with their relationship with their partners, including lack of intimacy (Hanington et al, 2012). The actual pregnancy, so the antenatal period, appears to be the most stressful time for men in the transition to fatherhood (Condon et al, 2004) as well as a lack of opportunity to bond with the baby until after the birth – unlike mothers who can bond during the pregnancy (Edhborg et al, 2005).
 

The impact on children

Fathers who suffer with PND are more likely to display negative parenting towards their children and this can have a detrimental effect on the child’s overall development (Wee et al, 2013). Davis and Davis (2011) found depressed fathers are more likely to smack their children compared with fathers who are not depressed. A substantial UK/USA study found severe PND in fathers was associated with high levels of emotional and behavioural problems in their children, particularly in their sons as young as 3.5 years (Ramchandani et al, 2005). Wilson and Durbin (2010) published a meta-analytic review of 28 studies looking at the overall development of the infant and examining the effects of paternal depression on parenting behaviour. The findings indicated negative parenting behaviour such as decreased positive emotion, warmth, sensitivity and increased hostility, intrusiveness, and disengagement was observed in fathers with depression. The review identified depressed fathers are less likely to sing, read or tell stories to their children and this may have a negative impact on speech development in the first year of life (Paulson et al, 2006). It also reports infants of depressed fathers smile and laugh less than infants of non-depressed (Ramchandani et al, 2005) and have more fussy temperaments (Dave et al, 2005).
 

Lack of support

Generally, there is lack of understanding and a poor support network for fathers suffering with PND. Often partners and other family members underestimate the paternal role and the difficulties fathers may encounter during the transition to fatherhood (Kim and Swain, 2007). For fathers, being supported may ease the transition to fatherhood during the postpartum period (Kim and Swain, 2007). Similarly, healthcare professionals need to offer more structured support.

The health visitor plays a pivotal role in the promotion of mental wellbeing (DH, 2007) and is considered the linchpin in the detection and support to mothers at risk of experiencing PND (NICE, 2016). However, national guidelines for assessing fathers’ mental health and emotional wellbeing during the transition to parenthood have yet to be recognised within the health visiting service, and fathers’ distress usually goes undetected (Kim and Swain, 2007). Davey et al (2006) reports fathers feel isolated and frustrated by their inability to understand and deal with their own PND, but found that their stress levels significantly reduced when they engaged and shared their experiences with peers and professionals. Unfortunately, healthcare professionals’ awareness of paternal PND is limited because of the persistent perception that only mothers suffer from it (Ramchandani and Stein, 2008) and therefore, target screening and support programmes for fathers are virtually non-existent.
 

Recommendations for clinical practice

Given the findings of my review, these are my suggestions for improvements in clinical practice: 

  • Screening programmes should be considered for both parents. Currently there is no systematic approach to assessing fathers for depression in the postnatal period. Practitioners may want to consider using a self-reporting questionnaire for PND for fathers as well as for mothers.
  • Encourage more media and celebrity coverage about the condition to reduce social stigma.Public policy does not reflect the importance of screening fathers for PND. Clinicians need to challenge government policy to ensure paternal PND receives the same considerations in policy as maternal PND.
  • Researchers need to consider conducting international and cross-cultural studies to determine if there are similarities and differences in paternal PND in different cultures and countries.
     

Suggestions for future research

I have identified the following areas where there is a need for further research:

  • Research assessing the early identification and intervention to address mental health needs of fathers may be required.
  • More longitudinal studies to assess the impact of paternal PND on child development and potential child psychology are needed.
  • Recruitment of fathers into research studies involving children appears to be challenging. Therefore a better understanding of factors contributing to low participation rates in studies needs to be examined.
  • Underrepresentation of certain groups appears problematic and this factor also needs to be addressed. It is important to study fathers in non-traditional settings, such as stay-at-home fathers, non-biological fathers, or single fathers.
     

Conclusions

The importance of supporting women during the transition to parenthood has long been recognised, but similar considerations do not appear to have extended to fathers.

There has been an underestimation of the impact of the fathers’ role in child development and health professionals need to recognise that fathers play an essential role in supporting development in their children (Roberts et al, 2006). Current evidence suggests paternal PND rates are on the increase and has a deleterious effect on child development and child behaviour to a degree like that seen in maternal depression (Wilson and Durbin, 2010).

Therefore, understanding paternal PND and its effects on child development needs equal consideration as its maternal counterpart.


Helen Knapman works as a flying start health visitor for the Aneurin Bevan University Health Board, Newport, South Wales.



Resources

  • Find advice from NCT at bit.ly/NCT_paternalPND
  • The Fatherhoodinstitute.org has a wealth of information
  • Fathers mental health campaigner Mark Williams set up reachingoutpmh.co.uk
  • Pandasfoundation.org.uk has a dedicated Facebook page


References

Bielawska-Batorowicz E, Kossakowska-Petyrcka K. (2006) Depressive mood in men after the birth of their offspring in relation to a partner’s depression, social support, fathers’ personality and prenatal expectations. Journal of Reproductive and Infant Psychology 24: 21-29.
 

Condon JT, Boyce P, Corkindale C. (2004) The first-time fathers study: a prospective study of the mental health and wellbeing of men during the transition to parenthood. Australian and New Zealand Journal of Psychiatry 38(1-2):56-64.
 

Dave S Nazareth I Sherr L and Senior R 2005. The association of paternal mood and infant temperament: A pilot study. British Journal of Developmental Psychology 609-621.

Davey S, Dziurwiec S, O’Brien-Malone A. (2006) Men’s Voices: Postnatal Depression from the perspective of male partners. Qualitative Health Research 16(2): 206-20
 

Davis RN, Davis MM, Freed GL, Clark SJ. (2011) Father’s depression related to positive and negative parenting behaviours with 1-year-old children. Paediatrics.
 

Department of Health. (2007) Facing the Future: a review of the role of health visitors. London: The Stationery Office.
 

Edhborg M, Matthiesen AS, Lundh W, Widstrom AM. (2005) Some early indicators for depressive symptoms and bonding 2 months postpartum: A study of new mothers and fathers. Archives Womens Mental Health 8: 221-31. 
 

Goodman J. (2004) Paternal postpartum depression, its relationship to maternal depression, and implications for family health. Journal of Advanced Nursing 45(1):26-35.
 

Halle C, Dowd T, Fowler C, Rissel K, Hennessy K, MacNevin R, Nelson MA. (2008). Supporting fathers in the transition to parenthood. Contemporary Nurse 31: 57-70.
 

Hanington L, Heron J, Stein A, Ramchandani P.  (2012). Parental depression and child outcomes – is marital conflict the missing link? Child: care, health and development 38(4): 520-529.
 

Kim P, Swain J. (2007) Sad dads: paternal postpartum depression. Psychiatry  4(2): 35-47.
 

Knapman H (2014). Is there a link between paternal postnatal depression and developmental delay in children aged 0-6 years. A systematic review of the literature (dissertation).
 

National Institute of Clinical Excellence (NICE) 2016. Antenatal and postnatal mental health: clinical management and service guidance. HMSO.
 

Quevedo L, Da Silva A, Coelho F, Pinheiro KA, Horta BL, Kapczinski F, Pinheiro RT. (2011) Risk of suicide and mixed episode in men in the postpartum period. Journal of Affective Disorders 132(1-2): 243–246.
 

Paulson JF, Dauber S, Leiferman, JA. (2006) Individual and combined effects of postpartum depression in mothers and fathers on parenting behaviour. Paediatrics 118(2):659-667.
 

Paulson JF, Bazeman SD 2010. Prenatal and Postnatal Depression in Fathers and Its Association with Maternal depression: A Meta-Analysis. JAMA 303(19):1961-1969.
 

Ramchandani PG, Stein A, O’Connor T, Heron J, Murray L, Evans J. (2008) Depression in men in the postnatal period and later child psychopathology: a population cohort study. Journal of the American Academy of Child Adolescent Psychiatry 47(4):390-398.
 

Roberts SL, Bushnell JA, Collings SC, Prudie GL. (2006). Psychological health of men with partners who have postpartum depression. Australian and New Zealand Journal of Psychiatry 40(8):704-11.
 

Royal College of Psychiatrists. (2015). Postnatal Depression. See: http://www.rcpsych.ac.uk/healthadvice/problemsanddisorders/postnataldepression.aspx (accessed 23 March 2018).
 

Ramchandani PG, Stein A, Evans J, O’Connor TG and the ALSPAC study team. (2005) Paternal depression in the postnatal period and child development: a prospective population study. The Lancet 365 (9478):2201-5.
 

Wee Y, Pier C, Milgrom J, Richardson B, Fisher J, Skouteris, H. (2013) Fathers’ mental health during the antenatal and postnatal periods: Knowledge, recommendations and interventions. British Journal of Midwifery 21(5):342-353.
 

Wilson S, Durbin C. (2010) Effects of paternal depression on fathers’ parenting behaviour: a meta-analytic review. Clinical Psychology Review 30(2):167-180 

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