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Clinical Research: Men’s experiences of partners’ postnatal depression

Author Godfrey Muchena, MSc, BSc, Diploma Mental Health Nursing, Diploma Education, RMN, is community mental health nurse, crisis assessment and treatment team, Hertfordshire Partnership NHS Foundation Trust.

Abstract Muchena, G. (2007) Men’s experiences of partners’ postnatal mental illness. Nursing Times; 103: 48.

This study explored men’s reactions to fatherhood and their knowledge and attitudes about postnatal mental illness. Men experienced significant psychological trauma when their partners were admitted to the mother-and-baby unit. They also experienced relationship and family problems, chronic sleep deprivation, financial constraints and reduced input at work. In some men, these factors and the psychological trauma combined may easily develop into mental ill-health.

Keywords: Mental health, Postnatal Depression, Management

Author Godfrey Muchena, MSc, BSc, Diploma Mental Health Nursing, Diploma Education, RMN, is community mental health nurse, crisis assessment and treatment team, Hertfordshire Partnership NHS Foundation Trust.

Abstract Muchena, G. (2007) Men’s experiences of partners’ postnatal mental illness. Extended version of Nursing Times; 103: 48, 32-33.

This study explored men’s reactions to fatherhood and their knowledge and attitudes about postnatal mental illness. Men experienced significant psychological trauma when their partners were admitted to the mother-and-baby unit. They also experienced relationship and family problems, chronic sleep deprivation, financial constraints and reduced input at work. In some men, these factors and the psychological trauma combined may easily develop into mental ill-health.

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BACKGROUND: Investigating men’s subjective experiences when their partners are admitted to hospital with postnatal mental illness offers insight into men’s needs at this time.

AIM: To discover men’s reactions to fatherhood and explore their knowledge and attitudes about postnatal mental illness. The study also aimed to differentiate men’s fatherhood experiences between subgroups.

METHOD: Semi-structured interviews were used to gather information about participants’ experiences. A total of eight men were divided into two groups of four, each representing those whose partners had puerperal psychosis or postnatal depression. The two groups were divided into four subgroups, representing inpatient and post-discharge partners. Data was analysed by thematic analysis procedures.

RESULTS AND DISCUSSION: Men experience significant psychological trauma when their partners are admitted to the mother-and-baby unit. They also experience relationship and family problems, chronic sleep deprivation, financial constraints and reduced input at work. In some men, these factors and the psychological trauma combined may easily develop into mental ill-health. However, men are generally reluctant to seek professional help from mainstream services.

CONCLUSION: Men’s difficulties following partners’ admission to hospital may be quickly resolved, but some fathers may develop mental illness if help is not sought.


Introduction
The aim of this study was to investigate the experiences of men whose spouses or partners were admitted to the mother-and-baby unit with postnatal psychiatric illness. The focus was to gain an insight of their reaction, attitudes, coping strategies and knowledge about stressors. The study also aimed to understand fathers’ needs through subjective reports and explore their expectations of the fatherhood role.

The two main diagnoses of puerperal psychosis and postnatal depression were used in determining differences in experience between male partners and how they confronted the reality of life change from a social, financial, cultural and relationship perspective.
Another dimension was to examine the experiential differences of fathers when their partners received treatment as inpatients or in the community.


Literature review
There is a small body of evidence that points to an association between a mother’s depression and the subsequent report of depression in her partner (Ballard et al, 1994).
Zilboorg (1931) pioneered work to investigate fatherhood experiences through psychoanalytical case studies. These studies revealed a trend of psychiatric illness within psychodynamics of fatherhood as well.

Traditionally perceived male characteristics - such as being physically and emotionally strong and self-contained - impede men’s ability to either seek help or show vulnerability. It has been noted that men’s difficulty in articulating their needs and experiences is a major barrier in seeking professional advice (Tammentie, 2004).

It is well documented that new fathers are reluctant to admit that they are suffering from postnatal depression because of a macho culture. Postnatal depression can affect men as well as women and often proves to be more difficult for men. Women open up and share their problems. However, men prefer to go to a pub and talk about other matters (Fathers Direct, 2007).

The widespread belief that postnatal depression only affects women is a myth and is contributing towards a situation where fathers fear to speak out. Many healthcare professionals now believe the stigma that prevents men from admitting to having depression is a major cause of suicide in young men (Department of Health, 1999b).

Growing evidence suggests that up to one in 14 fathers may suffer from postnatal depression. This may be an underestimation because the literature indicates that many men choose to remain silent about this (Fathers Direct, 2007).

Postnatal psychiatric illness is a substantial public health problem affecting 8-15% of all newly delivered mothers and leading to long-term adverse consequences for families. Postnatal depression has been identified in the National Service Framework for Mental Health as one of the core diagnoses for which primary care teams must develop clinical guidelines (DH, 1999a). The implementation of this guidance is the responsibility of each NHS trust and is an essential part of clinical governance (NICE, 2007).

Although this development was considered as a long overdue step towards providing inclusive services, it was condemned as absurd. Critics argued that this was ‘political correctness’ and that postnatal depression is caused purely by women’s hormonal and major physical changes during pregnancy and birth (Baron, 1999).

However, this view can be criticised for being too medically orientated. Understanding mental health or ill health in contemporary practice involves other psycho/social aspects.


Method Setting
This study was based on a psychiatric mother-and-baby unit in Hertfordshire. The unit is a six-bed ward and forms part of the mental health unit in a local hospital. Here, mothers are admitted with their babies following a severe episode of postnatal mental illness.

The unit aims to offer comprehensive hospital-based care to mothers experiencing mental disorders associated with childbirth. It operates in a multidisciplinary team providing specialist mental health assessment and treatment in a safe and therapeutic environment.

While its aim is to facilitate bonding between mothers and their babies, efforts are also made to involve fathers in the care process. Fathers are encouraged to attend a group within the unit to allow them to share experiences of fatherhood. This fathers’ group provides an opportunity to seek knowledge and support for fathers and their families. Support is also offered by professionals based in the mother-and-baby unit to help men develop in their fathering roles.


Sample
The mother-and-baby unit admission and discharge book was used to select all names of mothers who had partners and were admitted in the study period of the past two years for random selection. For the purpose of this study, inpatient subjects were those admitted three months before random selection.

A total of 40 potential participants were listed and their contact details written against their names. The 40 names were divided into two groups: one group with partners of mothers diagnosed with postnatal depression and the other with puerperal psychosis. Some 24 fathers were selected for the postnatal depression group and 16 for puerperal psychosis.

Each group was divided into two subgroups: partners of inpatient mothers in one group and partners of those being cared for in the community – post-discharge - in the other (see Table 1 for numbers). Two partners were selected from each subgroup to give a total of eight study participants.


Table 1. Potential participants

Subjects

Postnatal depression

Puerperal psychosis

Total number of subjects

24

16

Total number of inpatient partners

8

11

Total number of post-discharge partners

16

5

Inclusion and exclusion criteria
Recruitment of participants was based on set criteria but these criteria did not include marital status, age, ethnic background or socio-economic class. The men’s partners had to have an established diagnosis of postnatal depression or puerperal psychosis as classified in the Diagnostic Statistical Manual (DSM IV) or the International Classification of Diseases (ICD 10) (WHO, 1992).

The men were cohabiting with their partners before and after the inpatient stay in the mother-and-baby unit. Couples with known long-standing marital/relationship problems were excluded from the study because this was thought to have a potential bearing on fathers’ subjective experiences, independently of their partners’ admission to the unit.

Fathers with a history of psychiatric service usage were also excluded, as this was thought to be a variable potentially shaping their subjective experiences of fatherhood regardless of partners’ admission.

These criteria were thought to be effective in eliminating bias and improving generalisation of results. Recruitment from each subgroup was carried out by random sampling.


Random sampling
Name tags of the 40 potential participants were prepared and placed in four boxes by category, as outlined in Table 1. Random sampling was carried out by picking two name tags from each box. A total of eight participants were selected from the four boxes and matched to their contact details on the list prepared earlier. An invitation letter and a study information pack were sent by post to all selected participants.

Codes were used to replace the participants’ names in order to protect their identity.


Data collection
Semi-structured interviews were used for the purpose of data collection. The eight participants were contacted by telephone to agree a suitable date and time for the interview. There was no strict order of who was interviewed first, as this did not affect how data was gathered.

The researcher conducted the interviews face to face. Each participant was interviewed once for an average of 40 minutes. A prepared interview schedule was used to guide the interviewer on the sequence of questioning and predetermined depth of the interviewee’s responses. A copy of the interview schedule can be seen in Appendix 1.


Data analysis
Thematic analysis procedures were used in this study. The researcher transcribed every individual tape, converting all the tape-recorded data into a verbatim transcript. Each transcribed interview was read to identify themes emerging from the data. Themes relevant to the aims and objectives of the study were identified and matched to respective items on the interview schedule. Patterns of fathers’ experiences were listed and these were generated from direct quotes or paraphrased ideas from the transcripts.


Ethical considerations
The researcher applied for and obtained ethical approval to carry out this study from his local NHS Research Ethics Committee. Their guidelines and requirements were adhered to throughout the study.

Participants were assured of anonymity attached to any of the research findings and to taped or transcribed material.


Results and discussion
In addition to a compromised lifestyle, disturbed routines and increased responsibility, partners of mothers admitted to the mother-and-baby unit experienced moderate to severe sleep deprivation.

The findings of this study provide further evidence to support those of Armstrong et al (1998). They suggest that the effects of chronic sleep deprivation – including clinically significant fatigue, compromised functioning and impaired cognitive capacity – are very important but previously underestimated factors in maternal and paternal distress.


Fathers’ attitudes to the baby
There was a general positive feeling towards the baby and the new fatherhood role.
However, this feeling was not sustained when the mother fell ill and was admitted to the mother-and-baby unit.

Only two participants expressed a lack of joy towards the new baby. They attributed their dissatisfaction with the child to lack of interaction and engagement in meaningful activities.

This outcome suggests that fathers are more interested in watching their babies grow and therefore play a passive role in supporting their partner emotionally and practically. It indicates that they believe that mothers naturally have more to do with babies and hence should assume more responsibilities.

The finding regarding fathers’ interest towards the new baby is supported by Dragonas et al (1992). They carried out a cross-cultural comparison study of transition to fatherhood for British and Greek fathers. The social class, age and parity distributions were similar in both populations but the culture and social structure experienced by each varied widely. Though higher in the Greek fathers, significant malaise was experienced by both after their children were born.


Financial problems
The birth of a baby and the mother’s admission caused problems for all families but especially for the younger ones. Financial problems brought conflicting thoughts for working fathers, as they found the extra costs of the new baby could not be met if working hours were reduced.

Some young fathers had less input at work because they had to accommodate their family needs, so had problems in trying to balance work and family life. More time was needed to make regular visits to the mother-and-baby unit. This inevitably affected input at work, routines of going straight home after work and finances because of the extra travelling.


Reactions to hospital admission
The men’s reaction to their partners’ admission to the inpatient unit was one of shock and disbelief. The deterioration in mothers’ postnatal conditions was so rapid that partners felt helpless and puzzled.

This finding suggests that fathers had no previous knowledge of detecting postnatal psychiatric illness in their partners. They did not know to whom they could turn nor how to deal with the situation. No meaningful help was received from community-based mental health teams except for GPs and one crisis resolution team who referred mothers to a specialist mother-and-baby unit. It is evident that partners experience heightened stress levels and psychological disturbances when they find themselves in this kind of situation.

This is important as Harvey and McGrath (1988) and Lovestone and Kumar (1993) found that many partners of women admitted to the mother-and-baby unit had a psychiatric disorder. Similar studies have found the rate of disturbance in such men seems to be higher than that in partners of patients with psychiatric disorders in general settings. A cross-sectional view of studies on partners of outpatients (Fadden et al, 1987), day patients (MacCarthy et al, 1989) and inpatients (Waring and Patton, 1984) - as cited in Lovestone and Kumar (1993) - showed that approximately one-third of relatives have symptoms of a mild disorder themselves.


Guilt and communication issues
The failure to detect the deteriorating condition in mothers brought much guilt for men, especially among those who were highly qualified healthcare professionals.

It can be argued that detecting mental illness in family members is not an easy task because it is often overlooked. Another explanation could be a fear of stigma attached to mental illness if fathers accessed mainstream services for their partners.

Fathers therefore carried a burden of stress related to their partners’ deteriorating condition. Outbursts of anger as well as feelings of sadness were commonly reported by participants as they attempted to process and deal with emerging experiences.

Communication between couples was characterised by distorted emotional feelings. Morgan et al (1997) agreed with this finding. Their study demonstrated that partners who experience felt guilty perceived their relationships to be strained.

Working at adult ways of communicating appears to take low priority following the arrival of an infant, with accurate information about personal feelings not being exchanged between partners. Morgan et al (1997) observed that women expect men to show initiative, realise that help is needed and what that help entails. They hope their partners read their minds, provide necessary support and perceive how their needs have changed since the arrival of the baby.

This situation is further complicated if the father is distanced by his partner as she takes total care and responsibility for the baby, believing she is indispensable and that her partner could not provide adequate help. This may contribute to lowering the man’s self-esteem. He too may be feeling unsure and be anxious and depressed.

Morgan et al (1997) showed that the most consistent theme expressed by men was exasperation due to the lack of appreciation for their attempts to offer emotional or practical help to their partners.


Men’s use of services
There was a general reluctance by fathers to access mainstream services in the event of experiencing psychological problems. Six out of the eight participants in this study experienced some psychological disturbance but only two sought professional help.

Fathers tended to use informal services such as chat rooms or telephone helplines, or sought emotional support from friends. Three fathers attempted to gain comfort by drinking alcohol with friends in pubs. These measures provided instant but evanescent relief from their psychological problems.

This finding supports the view of Ramchandani et al (2005) that traditional male characteristics such as being physically and emotionally strong may impede their ability to either seek help or show vulnerability.

Evans et al (2001) confirmed that new fathers are too frightened to admit they are suffering from postnatal depression because of a ‘macho culture’ among men. Postnatal depression can affect men just as it affects women and often proves to be more difficult for fathers. While women open up and share their problems, men prefer to go to a pub with friends and discuss other issues unrelated to fatherhood experiences.


Family structure
Deater-Deckard et al (1998) studied the family structure and depressive symptoms in men before and after the birth of a child. They explored the role of stressful life events, social and emotional support, the quality of partner relationship and socioeconomic circumstances.

The researchers concluded that men living in stepfamilies had significantly higher levels of depressive symptoms before and after birth than men belonging to more traditional families.

The effect of stepfamily status on depression was mediated by education, life events, social support, social networks and level of aggression in the partnership. They reported similarities in the patterns and correlations around depression after the birth of a child for men and women. These findings point to the importance of family and partnership ecology in the adjustment of men before or after the birth of a child.


Fathers’ mental health
Fathers experienced high stress levels as a result of delayed response from services. This means that mothers’ conditions further deteriorated ‘at the hands’ of helpless partners. It has been noted that prolonged stress and anxiety can easily develop into depression (Kleinman, 2001).

This British study supported this outcome by confirming that about 3% of all new fathers are prone to developing postnatal depression, particularly if their partner is depressed. The study examined common vulnerability factors including: old age; being a first-time parent; a small circle of friends; deprived social interaction; limited education; concurrent stressful life events; and the quality of relationship with partner.

Although there was a great sense of relief among fathers on admission of their partners to the mother-and-baby unit, generally fathers remained confused and anxious and, in others, sadness and depression prevailed. This finding shows that fathers felt reassured when mothers were admitted. However, in families of more than two children, fathers may have felt challenged when they considered their ‘inadequate’ parenting skills were then needed to look after the older children.

This observation is supported by the Father and Child project (www.fatherandchild.net.nz). It demonstrated that transition to fatherhood is a substantial change in a man’s life and one that fundamentally changes his role in the family. Some men continue to struggle with these changes, which can affect their mental health.

The implication is that a new father may experience the following: find it difficult to relate properly to his baby; be negligent about work commitments; be irritable; delay coming home from work; seek more solitude than usual; feel guilty about his small contribution; feel superfluous within the mother-baby harmony; or stop socialising. All these symptoms can indicate that adjustment problems have developed into depression.


Impact on relationships
Generally, partners felt that their marriages had ended following hospital admission. It appears that physical separation of the mother and the new baby broke the family unit and as a result affection within the relationship dwindled. While some partners re-established themselves in the relationships, others had sustained arguments and a ‘blame culture’ to the extent that relationships suffered irreparable damage.

It is worth noting that some relationships actually grew stronger as fathers tried to offer support through this predicament. However, it can also be argued that the strength in most of the relationships was based on the men’s attitude to preserving their ‘strong’ image within the family even though they themselves experienced high stress levels. They were reluctant to show their own stress levels to mothers for fear of aggravating their condition.


Views of services

Fathers were generally pleased with the service offered by the mother-and-baby unit. They did, however, expect a needs assessment to be carried out on admission rather than a few weeks later. The rationale was that any needs would surface at the time of crisis or on admission. Fathers needed to know about how to access childcare services, literature on partners’ diagnoses, fathers’ support groups, parenting skills classes and telephone helplines.


Comparisons between subgroups
In comparison, partners of women admitted with puerperal psychosis had a more challenging experience than those of mothers with postnatal depression.

Since the prevalence rate of puerperal psychosis is low, little is known about its prognosis in the general population. All partners were at least aware of the general symptoms of depression and could easily relate these to how their partners felt.

What is fundamental in this study is that the difference in diagnosis had no significant bearing on fathers’ experiences. The magnitude of adverse effects on partners was universal among all subgroups.

In the same context, partners of inpatient mothers experienced more stress than those who received treatment in the community. A hospital stay for mothers only provided transitory respite because the strain resumed post discharge.

Fathers felt their family unit had been broken, especially when they compared their experiences to men in the general population whose partners had not been admitted with postnatal psychiatric illnesses.


Conclusion
Research indicates that the impact of postnatal psychiatric disorder on partners is greater than that of general psychiatric illness because of the additional burdens of parenthood. However, according to this research, the psychotic or non-psychotic nature of the postnatal psychiatric disorder in mothers seems to have little bearing on the size of the impact on fathers.

This conclusion is supported by psychodynamic theorists, who have long emphasised that becoming a parent is a time of ‘psychological flux’ which, if disturbed by a partner’s mental illness, may result in psychological disturbance and mental ill-health in susceptible men (Jarvis, 1962; Benedek, 1959; Zilboorg, 1939; all as cited in Lovestone and Kumar, 1993).

When comparing partners of inpatient and post-discharge mothers, it appears that the hospital stay gives partners some respite although the adverse experiences largely remain.

Many depressive symptoms such as loss of libido, disturbed sleep and exhaustion occur as a normal part of the puerperium. However, if such symptoms persist over a long period of time and without formidable support networks, they can develop into mental health problems.

This study has achieved its aims by showing that some men experience psychological trauma when their partners are admitted to the mother-and-baby unit with postnatal mental illness. This could develop into psychiatric illness in some men who do not seek help.


Implications for practice
The study has highlighted a lack of appropriate resources for postnatal men to access help. It has shown that men do not access mainstream services when they become depressed. However, it is not fair to apportion blame to fathers alone, as it has been shown that services systematically exclude men when it comes to postnatal mental illness.

Given this evidence, healthcare professionals should devise approaches to better support men in their transition to fatherhood. Developing a screening tool equivalent to the Edinburgh Postnatal Depression Scale for men could be a starting point. In services, there is a need to change preconceived ideas and start valuing fathers’ experiences and understanding the differences between individual fathers.

Services should raise awareness and accept that transition to fatherhood can - in some circumstances - be a damaging experience for men. Access to antenatal classes by fathers should be facilitated and relevant factual literature and skill-based information disseminated as appropriate (see www.fathersdirect.com).

User-friendly services for men should be designed, taking into account their working hours to enhance accessibility. Mother-and-baby units are well placed to assess the needs of men as they try to support their partners.

Couple counselling and psychotherapy, provided when the mother has postnatal depression and with the aim of strengthening the relationship and improving depression, could be incorporated into primary care. More funding is needed to increase availability of resources for health visitors to carry out more thorough assessments on postnatal couples.

More funding could be directed towards increasing antenatal education about postnatal depression and, at the same time, involving fathers from an early stage in pregnancy through to birth and the postnatal phase.

Brief interventions using cognitive behavioural therapy and problem-solving approaches may be effective in reducing depressive symptoms in both men and women during the postnatal period.

Factors reported in this study should be drawn on to improve treatment and management strategies in a wide variety of primary and secondary care services (NICE, 2007).

Considering that stigma may contribute towards fathers’ cultural reluctance to access services, care packages should focus more on advocacy, empowerment and anti discrimination. Health promotion through the use of high-profile citizens may help change men’s attitudes.


Recommendations for future work
While all the quantitative research carried out so far is appreciated, more qualitative research needs to be done if the postnatal experience and problematic adjustment of men is to be understood. The aim should be to explore and develop low-cost interventions that prevent ill health in postnatal men.

Doctors and healthcare professionals dealing with families are ideally placed to detect depressive symptoms in new fathers. Therefore, they should lead in research initiatives that focus on depressed fathers and influence the development of appropriate and inclusive interventions to address fathers’ experiences.

Appendix 1

Interview schedule

1. The change and adaptation/transition to fatherhood
(a) What difference has the baby made to your life?
(b) Is there anything you especially enjoy about having the baby?
(c) Is there anything you have found particularly difficult about having the baby?

2. Adaptation to partner’s admission to the mother-and-baby unit
(a) What was your initial reaction to your partner’s admission?
(b) Describe in detail what your feelings are/were when this happened?
(c) How do you feel at present about the whole thing and your relationship with partner?

3. Coping after partner’s admission
(a) How far did your life change after your partner’s admission? Please classify your responses in the following categories: (1) social (2)cultural, (3) economic and (4) relational.
(b) How did these changes affect your day-to-day life?
(c) Did you seek help? / From whom? / What sort of help?

4. Needs analysis
(a) How much do you know about postnatal depression/puerperal psychosis?
(b) What sort of help do you/did you envisage receiving after your partner’s admission?
Is/was it accessible? How did you access it? Is it what you expected? How can service provision be improved to enhance its responsiveness to your needs?
(c) How would you compare your experiences as a parent to other parents'?


REFERENCES

Armstrong, K. et al (1998) Sleep deprivation or postnatal depression in later infancy: separating the chicken from the egg. Journal of Paediatric Child Health; 34: 263-266.

Ballard, C. et al (1994) Prevalence of postnatal psychiatric morbidity in mothers and fathers. British Journal of Psychiatry; 164: 782-788.

Baron, J.D. (1999) She had a Baby and Now I’m having a Melt-Down: What Every New Father Needs to Know About Marriage, Sex and Diapers. New York, NY: William Morrow and Company.

Deater-Deckard, K. et al (1998) The Avon longitudinal study of pregnancy and childhood study team. Family structure and depressive symptoms in men preceding and following the birth of a child. American Journal of Psychiatry; 155: 818-823.

Department of Health (1999a) National Service Framework for Mental Health: Modern Standards and Service Models. London: The Stationery Office: DH.

Department of Health (1999b) Saving Lives: Our Healthier Nation. London: The Stationery Office: DH.

Dragonas, T. et al (1992) Transition to fatherhood: a cross-cultural comparison. Journal of Psychosomatic Obstetrics and Gynaecology; 13: 1-19.

Evans, J. et al (2001) Cohort study of depressed mood during pregnancy and after childbirth. British Medical Journal; 323: 257-260.

Fadden et al (1987); MacCarthy et al (1989); and Waring and Patton (1984). Cited in: Lovestone, S., Kumar, R. (1993) Postnatal psychiatric illness: the impact on partners. British Journal of Psychiatry; 163: 210-216.

Fathers Direct (2007)
www.fathersdirect.com

Harvey, I., McGrath, G. (1988) Psychiatric morbidity in spouses of women admitted to the mother and baby unit. British Journal of Psychiatry; 152: 506-510.

Kleinman, K. (2001) Postpartum Husband: Practical Solutions for Living with Postpartum Depression. Philadelphia, PA: Xlibris Corporation.

Lovestone, S., Kumar, R. (1993) Postnatal psychiatric illness: the impact on partners. British Journal of Psychiatry; 163: 210-216.

Morgan, M. et al (1997) A group programme for postnatally depressed women and their partners. Journal of Advanced Nursing; 26: 913-920.

NICE (2007) Antenatal and Postnatal Mental Health. London: NICE.

Ramchandani, P. et al (2005) Paternal depression in the postnatal period and child development: a prospective population study. Lancet; 365: 9478, 2158-2159.

Tammentie, T. (2004) Family dynamics and postnatal depression. Journal of Psychiatric and Mental Health Nursing; 11: 141-149.

World Health Organization (1992) Mental Disorders: Glossary and Guide to their Classification in Accordance with the Tenth Revision of the International Classification of Disorders (ICD-10). Geneva: WHO.

Zilboorg, G. (1931) Depressive reactions related to parenthood. American Journal of Psychiatry; 10: 927-962.

Zilboorg, G. (1939); Benedek (1959); and Jarvis (1962). Cited in: Lovestone, S., Kumar, R. (1993) Postnatal psychiatric illness: the impact on partners. British Journal of Psychiatry; 163: 210-216.

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