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Psychological issues surrounding paternal perinatal mental health

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VOL: 101, ISSUE: 05, PAGE NO: 40

Thomas J. Currid, PGCE, BSc, RMN, is senior lecturer mental health, London South Bank University

The perinatal period has been defined as the period from conception to 24 months postpartum. It has been widely recognised that for women it brings an increased risk of affective disorders, psychotic illness and psychological distress (Department of Health, 2002). They might experience an exacerbation of pre-existing mental health disorders, such as depression, that were present in the antenatal period and have continued into the postnatal period, or a psychotic illness such as schizophrenia that was present before pregnancy and will continue throughout the mother's life.

The perinatal period has been defined as the period from conception to 24 months postpartum. It has been widely recognised that for women it brings an increased risk of affective disorders, psychotic illness and psychological distress (Department of Health, 2002). They might experience an exacerbation of pre-existing mental health disorders, such as depression, that were present in the antenatal period and have continued into the postnatal period, or a psychotic illness such as schizophrenia that was present before pregnancy and will continue throughout the mother's life.

For others, however, the perinatal period may bring about their first experience of mental health difficulties and psychological distress and may again be experienced in subsequent pregnancies. If these difficulties are left untreated, they may result in serious and cumulative negative consequences for the mother and the family unit as a whole (Deater-Deckard et al, 1998).

While study into this area has raised awareness of the problem and has brought about changes in practice and policy (DoH, 2002), there has been less attention given to paternal mental health issues, particularly in the perinatal period (Goodman, 2004; Matthey et al, 2000).

Lack of literature
The paucity of literature in this area may stem from the view that gender-specific factors such as pregnancy, obstetric complications, lactation and endocrine changes have a specific effect on women's mental health and may have a particularly adverse effect on her offspring (Areias et al, 1996). It may also be that the effects of mental health problems during this period are more serious for women when compared with the adverse psychological effects that it may have on men.

Other factors that may have led to this scarcity of studies may be underreporting by men who consider it unmanly to have such a problem. Men may not report the problem because of the embarrassment, stigma and fear of admitting to having psychological difficulties. It has also been suggested that men have been viewed negatively by some providers and policymakers because they are considered unreliable, irresponsible and unwilling to be helped. While this may have been the case historically due to cultural behavioural norms, we need to challenge these ideas and consider changes in men's attitudes, behaviours and roles.

Dynamics of a changing role
The father's role has changed significantly over the years from being a breadwinning, authoritarian figure to becoming more involved in 'hands-on' childcare (Draper, 2003a; Chandler and Field, 1997). Shemilt and O'Brien (2003) assert that changes in parental employment patterns and family structure are creating new socioeconomic and cultural contexts for what it means to be a father, and fathers now provide about one-third of total parental childcare. Others add that there is increasing pressure on fathers to be present at the birth of their child and to participate in antenatal classes (Draper, 2003a). Though such involvement may be seen as positive, it can create tensions for the mother who may feel that she is relinquishing control.

Morgan et al (1997) report that in a group programme for women with postnatal depression and their partners, the men reported that their attempts to support the women resulted in increased tensions between the partners and feelings of exasperation by the men because they felt unappreciated by their partners.

Daniel and Taylor (1999) suggest that practitioners may also ignore the positive contributions that men make. Observations by Edwards (1997) suggest that men tend to be regarded by social workers and health visitors as problematic whether they are present or absent - when they are absent they are seen as irresponsible, and when present they are considered to make extra demands on the mother and may be violent.

Fathers participating in labour and delivery have also reported negative attitudes from midwives. In a study by Chandler and Field (1997) fathers reported their presence being tolerated rather than welcomed as necessary and that they were not included in discussions.

Paternal psychological experiences in the perinatal period
Antenatal period

There are several studies that provide insight into the male experience of the antenatal period. Donovan (1995) reports feelings of ambivalence in the early stages of pregnancy and concerns about coping with changing lifestyles and roles. Others reported troubling feelings around the transition process including unresolved feelings about their sexual maturity and development, vulnerability, problems with their masculinity and feeling that the baby is not yet real to them (Draper, 2003b).

Other processes may include dealing with feelings of marginalisation or isolation, often brought about by the increased attention that their pregnant partner receives (Gjerdingen and Centre, 2003).

Many men deal with these feelings without any detrimental effects, however, many others experience more serious and complex feelings that can have adverse effects on their health. An earlier study by Raskin et al (1990) which assessed symptoms of depression in 86 couples during pregnancy and after childbirth, found that 59.3 per cent (n=51) of the couples had at least one symptomatic spouse during the transition to parenthood and both spouses were symptomatic in 11.1 per cent of the affected couples during pregnancy. Matthey et al (2000) at four points of the antenatal period, found cumulative rates of depression to be 5.3 per cent in men.

Deater-Deckard et al (1998) studied rates of depression in a sample of 7,018 men in different family structures during their partner's pregnancy and eight weeks postpartum. They found that stepfathers had significantly higher levels of depressive symptoms before and after the birth than biological fathers. They also found that depression in stepfathers depended on the six risk factors listed in Box 1.

While it is accepted that a woman's psychological well-being is more vulnerable during the antenatal period, it can be seen that it is also a time when men are at increased risk and are also vulnerable to poor mental health. Supporting this, Thomas and Upton (2000) assert that men face a period of change, upheaval and uncertainty during their partner's pregnancy. They argue that men can experience psychological, social, emotional and even physical changes during a partner's pregnancy and Western society, unlike many other societies, does not recognise the massive impact that pregnancy can have on the expectant father.

Health and social care personnel need to acknowledge this and provide support. Offering support within this period may encourage fathers to come forward and so reduce the number of cases of distress and depression in men in the postnatal period.

Postnatal period

In a review of the literature of paternal postpartum depression, Goodman (2004) found that it was not a commonly recognised phenomenon. While postnatal depression is an accepted condition in women, it has yet to be classified as a condition experienced by men.

Some argue that postnatal depression in men is 'political correctness gone mad', and yet studies on depressive symptoms in men following childbirth have found that they do exist.

In their study of correlates of postnatal depression in mothers and fathers, Areias et al (1996) found that 4.8 per cent of men were depressed at three months postpartum and 28.6 per cent were depressed at 12 months postpartum. Using three different scales, the Edinburgh postnatal depression scale, the Beck depression inventory and the general health questionnaire, Dudley et al (2001) found that 48.9 per cent of fathers exceeded the threshold on one or more of the three screening tools. Matthey et al (2000) in their study of validation of the Edinburgh postnatal depression scale found a rate of 2.9 per cent for depression in fathers at six weeks post partum. They add that though their figure may appear to be somewhat lower than rates in other studies, it is consistent when compared with large community samples.

Katz et al (1993) found that men and women display signs of depression in different ways, with men more likely to exhibit signs of hostility. Therefore it is important for health care workers to recognise these different signs of depression. Alexander (2001) asserts that men may need more careful screening and more than one assessment may be needed to gain a more informed presentation.

Psychological aspects must not just become the sole focus when screening men in the postnatal period. Fathers have a number of biopsychosocial needs and therefore attention must be given to the physical. As is the practice for women in the perinatal period, full global assessments must also be offered to men to establish an overview of their general welfare. Global assessments would provide a more comprehensive screening of the partner's health status and may lead to either a faster detection of problems, early signs of illness or identification of symptoms that may be manifesting in other types of presentations. For example, depressed men may present with somatic complaints and other physical symptoms that need to be fully explored to determine whether there is a physical cause or whether the physical symptoms are masking depression (Alexander, 2001).

One way of facilitating and developing this new practice may be to invite the father to accompany his partner to antenatal and postnatal appointments. Although it may prove difficult for fathers to attend due to employment status and work patterns, this will continue if appointment times are restricted to between the hours of nine to five. To further develop this approach, we may need to review paternity leave entitlement and extend it to the antenatal period rather than just the postnatal period to which it currently applies.

Predisposing and precipitating factors
There are several predictive risk factors of psychological distress and illness in men before and after childbirth. These factors include the state of the relationships, presence of depression in their partners, socioeconomic status and a history of previous depression or other neurotic illness. In an exploratory study of relationships in depressed men, Alexander (2001) found that none of the married men in his sample had a close confiding relationship and that this was a major predisposing factor in depression. A dominant belief among the participants was that the disclosure of thoughts and feelings would burden those close to them.

Other variables in relationships found to be predictive of psychological distress were interpersonal sensitivity and partner satisfaction. Harvey and McGrath (1988) found that poorer marital relationships were evident in 42 per cent of men who met the criteria for psychiatric illness. Gjerdingen and Centre (2003) found that while postpartum health was related to several factors, the mothers' level of satisfaction with their partner was significantly related to both the mother's and father's mental health, therefore suggesting that happiness and stability in relationships contribute to overall mental health.

Looking after or caring for a partner who is ill can also predispose carers to many stresses and strains. Several studies correlate and demonstrate the effects that maternal depression can have on levels of depression in their partners. Studies by Matthey et al (2000), Areias et al (1996) and Ballard et al (1994) all found that partners of depressed mothers were significantly more likely to be depressed or show other signs of emotional distress, particularly in stepfamilies and in the partners of single mothers (Deater-Deckard et al, 1998). Qualitative studies also outline some of the negative experiences and feelings that men go through when their partner has mental health problems (Morgan et al, 1997). Emerging themes include the difficulties in trying to cope with the demands that a new baby brings while also trying to tend to the partner's needs, the needs of the family and working full-time.

Implications for practice
Perinatal mental health is a concern for all health and social care professionals. While it is becoming more prominent in the literature, much of it still tends to focus on the needs of women in this period. Though investigation and policy development into women's perinatal issues are important, we must ensure men are also included. Therefore we must be mindful of not taking a sexist approach to this neglected area of health care.

Generally speaking, men's health is unnecessarily poor and under-researched. In terms of mental health, a study in Scotland suggests that admission rates for depression among men rose from 3.1 per 10,000 to 3.5 during the period 1980 to 1995 (Shajahan and Cavanagh, 1998). Men also tend to suffer more from psychosis and are three times more likely than women to take their own life (Office for National Statistics, 2001). While policies exist on mainstreaming women's mental health (DoH, 2002), no such documents are as yet available for men. As care providers we must act upon these facts and take steps immediately to tackle these inequalities.

It has been considered difficult to engage men with health services in the past and the responsibility has been placed on the client group to make their needs known. This notion now needs to be examined and challenged. Placing the onus on the individual to come forward detracts from the responsibility of care providers in their roles of health screening, surveillance and promotion.

Men do care about their health and welcome services delivered sensitively. One such project in Essex is a telephone helpline for men who experience difficulties in the perinatal period. Although this service has yet to be evaluated, it is a good example of a modern innovative approach that reflects evolving health care needs.

Staff working in the field of perinatal care need to engage in education and training programmes to better understand their role.

Learning objectives
Each week Nursing Times publishes a guided learning article with reflection points to help you with your CPD. After reading the article you should be able to:

- Raise your awareness of paternal perinatal depression;

- Know the possible causes of the condition;

- Understand why it may have been overlooked;

- Identify some strategies to deal with paternal perinatal depression.

Guided reflection
Use the following points to write a reflection for your PREP portfolio:

- Describe why you read this article and its relevance to your practice;

- Summarise the main points of the article;

- Identify a new piece of knowledge you have learnt about paternal perinatal depression;

- Consider how you will use this information in your future practice;

- How will you follow up what you have learnt from this article?

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