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Fathers and postnatal depression

Studies in postnatal depression (PND) have estimated the condition affects between one in ten and seven in ten women. Research into the causes and effect has escalated during the past 10 years with a clear recognition of the importance of early detection and treatment of the illness for both the mother, in terms of her recovery, and the infant, in terms of improving cognitive and physical development.

Recently, there has been increasing evidence of the impact a mother's mental health can have, not only on her infant but on also on her partner. Fathers are now, albeit reluctantly, admitting to the difficulties they sometimes encounter when the mother of their child suffers from postnatal depression.

Whereas the physiological impact of pregnancy and childbirth is often freely discussed between health professionals and mothers, there is little to suggest that men are always included in the discussions about maternal mental health or the possibility of a depressive disorder occurring during the perinatal period. Often fathers feel disenfranchised by their lack of knowledge or new information during the antenatal period, and are often worried by their perceived affect of the pregnancy and impending birth on their relationship.

One study found that men who were worried by the effects of the pregnancy had continued problems with their role as a parent and partner.1 Unsurprisingly, during research by Draper,2 it was found that most fathers wanted to be included in all aspects of the pregnancy. They felt that once they were armed with a sound knowledge of the expectations of this period, they were more secure in their ability to deal effectively with the transition to fatherhood. Further research by Kurstjens and Wolke3 found that the engagement of fathers in the care of the mother and unborn child during the antenatal period has been shown to have positive mental health outcomes.

Morgan et al.4 studied fathers who participated in postnatal depression programmes and identified a lack of understanding between couples, and recognised that men and women have differing coping styles. Women tend to talk about their feelings whereas men consider their feelings personal and should be hidden from the public gaze. Men often decide that relationship problems should be rectified within the partnership without the need for outside interventions. Everingham et al.5 argued that the promotion of positive interventions might enhance the communication between the couple and strengthen their relationship.

Should, however, the complexities of the relationship be too much of an encumbrance, fathers may become distressed and frustrated because of their inability to offer the necessary help and support. They may withdraw into and find solace in an activity or sport with which they feel more comfortable and in control.

Depression in fathers
The most common risk factors associated with depression in men postnatally were poor social support (or the perception of poor social support) and low emotional support or the perception of such.6,7 A difficult relationship with her partner has been identified as one of the predictive risk factors for postnatal anxiety and depression.8,9 In some cases it was felt that the mother's interpretation of not coping was precipitated by her own high expectations, and her subsequent inability to manage only compounded her failings.

A lack of understanding by the father resulted in a failure to communicate and inevitably placed significant pressure on the relationship. In some instances this caused the father to withdraw from the relationship and the care of his infant, with the intensity of the situation causing the father himself to become depressed.10,11,12

That is, however, with the presupposition that that the relationship was fully functioning prior to the pregnancy and both parties felt supported and prepared for the birth.13 Research by Deklyen et al.14 and Mao et al.15 found that if the relationship was tenuous this might have future repercussions, not only for the mother but for the father's mental health. As the mother sought support from the father, equally the father sought support from the mother. If the mother is herself depressed, this adds to the friction within the relationship, and this paradox can only lead to further disharmony.

Fathers' understanding of PND
The inability of some fathers to cope with or understand the process of maternal depression acts as strong factor.16 In studies, some of the fathers had difficulty understanding the trajectory of the illness of postnatal depression and were unaware of the consequences for the mother, their infant and themselves.

They hoped it was a temporary transition which would resolve in time. There are often unrealistic expectations of society for fathers, particularly young or inexperienced ones, to understand or cope with the emotional demands made upon them, not only by their partner but their new infant. Many fathers feel ill-equipped to deal with the situation.17,18

The role of the father in PND
The influence of fathers during the child's infancy when mothers are suffering from perinatal illness cannot be underestimated. Where parent-infant bonding is an issue, it is found that the interaction of the father is crucial. The highly effective behaviour of the infant, crying, clinging or making eye contact, ensures that a parent or carer is always on hand to care.19,20

Impaired maternal mental health has adverse effects on their infant, socially, emotionally, behaviourally, and cognitively.3 If this input from the mother is missed during the early years because of a period of depression, the child has little means of catching up and may be unable to recapture what has been missed.20

The father may be in a position to provide the necessary stimulation by engaging the infant in play or social interaction.22 This is supported in a study22 which found that fathers can protect infants from the more negative effects of their mother's condition. Infants respond favourably to their fathers when social communication and responses have been denied by their mothers. Ramchandani et al.23 found an association between the father's depression and later behavioural problems - for example, hyperactivity - in boys. This normally occurred around 3.5 years of age.

The long-term implications in retrospective studies found that women who had depressed mothers were less likely to develop the depression themselves if they had a sound relationship with their father.24,25 Therefore preparing fathers for a good relationship with their child may have vital consequences in the future.

Fathers and health professionals
The needs of the partner of a depressed mother may sometimes be ignored, and the mother's management and treatment decided upon without referring to the father's views or sometimes, involvement. Gilligan et al.18 found that fathers often feel marginalised and would rather avoid any confrontation with health professionals, often because they may feel they are wholly responsible for, or that their presence might exacerbate, the situation. It is important therefore to understand the father's position.

The social expectations of men often preclude them from disclosing their feelings. There is a tendency for men to confide their personal concerns to smaller networks of individuals, as they often fear they risk rejection should they admit to them publically. The importance of groups is highlighted by Hay26 who suggests that men are more likely than women to reminisce about shared experiences and similarities, which helps to create a form of solidarity within the group.

Davey et al.27 reported that fathers who felt isolated and frustrated by their inability to deal and understand with postnatal depression found their stress levels were significantly reduced when they were allowed to share their experiences in a group situation with their peers.

There is little evidence of group programmes for fathers in the UK, but several postnatal groups for mothers who have PND have been successful and resulted in a significant decrease in symptoms.28,4 Salinas29 conducted groups for fathers in parent training which proved to be successful. Although the evidence within the literature is limited, anecdotal evidence suggests that current fathers' groups are well attended and have demonstrated positive results with the continued engagement of the men.

The future
There is growing evidence of the importance of planning and implementing future care by health professionals to incorporate the perspectives of the father. Raising awareness of the complex issues in perinatal mental health may lead to a greater understanding of the role of the father as a partner, and address the deeper needs and understanding of the father's role in child care.

This added knowledge might help with the collaboration of health and social services to support the family as a whole unit and lead onto further research into the paternal role. There is increasing evidence that postnatal depression is a significant issue for both fathers and mothers. The importance of partnership working within the family is clearly demonstrated.

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