New fathers are at increased risk of mental ill health, and their needs should be assessed along with those of the mother and the baby
Authors: Jane Hanley is a senior honorary lecturer in perinatal mental health at Swansea University and consultant trainer manager in perinatal mental health at PMH Training and Development Services. Mark Williams is an author, professional public speaker and fathers’ mental health trainer with Jane Hanley’s PMH training and activist for men’s mental health, and the founder of Fathers Reaching Out.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here
The mental health of new mothers is generally well addressed, but what about that of new fathers? In recent years, health professionals have become more aware of perinatal mental health issues in women, and support for mothers has improved. However, fathers can also be affected by mental ill health (Goodman, 2004): figures show that around one in 10 experience postnatal depression (National Childbirth Trust, 2016). Fathers can also experience antenatal anxiety and perinatal depression, and the number of suicides among men increases in the age range of 30-44 years, often around the time when men tend to become fathers (Bjerkeset, 2008).
The awareness of paternal mental ill health is increasing, but in practice fathers receive little support, if any. National Institute for Health and Care Excellence guidelines on antenatal and postnatal mental health (National Institute for Health and Care Excellence, 2015) do not cover what happens to men in the perinatal period.
Mark Williams, who experienced post-natal depression and went on to create the charity Fathers Reaching Out, says: “I’ve spoken to fathers with bipolar disorder, schizophrenia, clinical depression, anxiety and other mental health illnesses who have no support plan in place at this crucial time. We must bring everything together, because if one piece of the jigsaw doesn’t fit, things can go terribly wrong.” It is crucial that nurses, midwives and health visitors are aware of these issues, understand the mental health needs of new fathers, and know what to do to help, including when to refer to a clinical perinatal mental health nurse specialist (CPMHNS).
Causes, symptoms and effects
It has been postulated that one of the causes of paternal mental ill health in the perinatal period could be the decrease in the father’s testosterone levels and an increase in oestrogen levels (Carnaham and Perry, 2004). There is some evidence linking low as well as high testosterone to depression in women (Rohr, 2002).
Socioeconomic and psychological causes include men’s sense of loss or uncertainty regarding their roles; a strain on the family’s finances; a smaller circle of friends; men’s difficulties in talking about what they are going through; and fewer people in whom to confide, particularly since their partner might not be able to provide emotional or psychological support because she is busy looking after the child, or because she is depressed herself. See Box 1 for a list of common symptoms.
Studies have also shown that a depressed father may talk to his child using more negative and critical utterances; that the process of secure attachment can be disrupted and the father–child interaction may be jeopardised; and it is possible that the father will be less sensitive to the child’s cues, which will disrupt the process of mutual regulation (Sethna et al, 2012; Ramchandi et al, 2008).
Rather than seek help, men will often self-medicate or compensate, and may:
- Misuse prescription medication;
- Increase their intake of drugs, alcohol, tobacco and/or caffeine;
- Stay longer in the workplace;
- Engage in impulsive risk-taking behaviour, such as reckless driving or promiscuous sex (Courtney, 2000).
If the problems are not addressed, his relationship with his partner and family could suffer. Consequences for the child may include poor social interactions and lower cognitive development in later life.
Role of nurses
Fathers should be included in care planning and involved in the care of their child and partner, and should have their mental health taken into consideration. Health professionals working with new parents often do not know the father’s mental health history, but the added strain of coping with the arrival of a child can trigger an episode of mental ill health whether or not this has occurred before.
If a father is exhibiting symptoms of anxiety or depression, several assessment tools are available. The easiest to access is the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al, 1987), which has been validated for fathers (Edmonson et al, 2010). At a cut-off score of over 10, it has a reasonable sensitivity and specificity. However, using the EPDS requires specific training, so nurses who do not have this training should refer to a CPMHNS if they have concerns.
If there are concerns about a father’s mental health, following a discussion with him, he should be referred to his GP and/or the specialist perinatal mental health team.
Role of specialist nurses
Clinical specialist nurses play a key role both in supporting fathers and in helping other staff to do so (van Doesem et al, 2008). Their role includes:
- Listening to fathers to help them identify and overcome challenges;
- Exploring fathers’ experience of the birth and attitudes to their child;
- Understanding there may be a history of mental illness or learning disability;
- Discussing treatment and resources – talking therapies, other agencies, medication, websites, apps and more;
- Increasing front-line staff’s awareness of paternal mental ill health;
- Training in, and implementing the use of an assessment tool;
- Sharing best practice and care plans;
- Encouraging the use of person-centred risk assessments and care plans;
- Ensuring the checklist used for care planning includes fathers’ physical wellbeing, general lifestyle, and alcohol and drug misuse.
Despite its potential negative effects on families, perinatal mental ill health in fathers is often under-recognised and under-treated. Nurses working with parents of young babies can play an important role in recognising fathers at risk of mental ill health and ensuring they are referred to specialist services where necessary.
Box 1. Common symptoms
- Fathers affected by perinatal mental health issues tend to:
- Report an increase in physical problems;
- Experience low mood, loss of interest and loss of joy;
- Put on weight;
- Complain of problems with concentration and motivation;
- Feel discouraged;
- Have increased feelings of fatigue;
- Have increased feelings of frustration, anger and/or irritability, as well as increased violent behaviour, sometimes resulting in conflict with others and isolation from their family;
- Experience a lack or loss of libido;
- Experience conflict between their roles as man, father, and partner or husband;
- Sometimes have suicidal thoughts.
Box 2. When a father should seek help
Fathers should be referred to a nurse specialist if they:
- Express feelings of low mood: tearfulness, sadness, desolation
- Do not seem as interested in life as before and find little joy in life
- Feel inadequate and/or unable to cope and conveys feelings of guilt, that they should be able to contribute more to family life
- Find it increasingly difficult to concentrate and complain of increasing physical problems
- Are easily irritated, with a tendency to deny their real feelings
- Begin eating more or less than usual
- Increase in alcohol or drug consumption
- Experience altered sleeping patterns, find it difficult to get off to sleep
Box 3. Guidance and resources
- The NHS Choices guide to stress, anxiety and depression
- Fathers Reaching Out
- The Samaritans
- Rethink Mental Illness
- The Marcé Society for Perinatal Mental Health
- NICE (2015) guideline on antenatal and postnatal mental health
- Around one in 10 fathers experiences postnatal depression
- Mental ill health in new fathers has negative consequences for them and their family life
- If a new father is showing symptoms of anxiety or depression, using an assessment tool will help diagnose the potential issues
- Fathers should be included in care planning and involved in the care of their child and partner
- Clinical specialist nurses play a key role both in supporting fathers and in helping other staff to do so
Bjerkeset O et al (2008) Gender differences in the association of mixed anxiety and depression with suicide. The British Journal of Psychiatry; 192: 6, 474-475.
Boyce P et al (1993) The Edinburgh Postnatal Depression Scale: validation for an Australian sample. The Australian and New Zealand Journal of Psychiatry; 27: 3, 472-476.
Carnahan RM, Perry PJ (2004) Depression in aging men: the role of testosterone. Drugs and Aging; 21: 6, 361-376.
Courtney WH (2000) Engendering health: a social constructionist examination of men’s health beliefs and behaviors. Psychology of Men and Masculinity; 1: 1, 4-15.
Cox JL et al (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry; 150: 782-786.
Edmondson OJ et al (2010) Depression in fathers in the postnatal period: assessment of the Edinburgh Postnatal Depression Scale as a screening measure. Journal of Affective Disorders; 125: 1-3, 365-368.
Fisher SD et al (2012) Partner report of paternal depression using the Edinburgh Postnatal Depression Scale-Partner. Archives of Women’s Mental Health; 15: 4, 283-288.
Goodman JH (2004) Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. Journal of Advanced Nursing; 45: 1, 26-35.
Kim P, Swain JE (2007) Sad dads: paternal postpartum depression. Psychiatry (Edgmont); 4: 2, 36-47.
National Childbirth Trust (2015) Postnatal Depression in Fathers.
Paulson JF, Bazemore SD (2010) Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. Journal of the American Medical Association; 303: 19, 1961-1969.
Paulson JF et al (2006) Individual and combined effects of postpartum depression in mothers and fathers on parenting behavior. Pediatrics; 118: 2, 659-668.
Ramchandini PG et al (2008) Depression in men in the postnatal period and later child psychopathology: a population cohort study. Journal of the American Academy of Child and Adolescent Psychiatry; 47: 4, 390-398.
Rohr UD (2002) The impact of testosterone imbalance on depression and women’s health. Maturitas: The European Menopause Journal; 41 Suppl 1: S25-46.
Sethna V et al (2012) Depressed fathers’ speech to their 3-month-old infants: a study of cognitive and mentalizing features in paternal speech. Psychological Medicine; 42: 11, 2361-2371.
van Doesum KT et al (2008) A randomized controlled trial of a home-visiting intervention aimed at preventing relationship problems in depressed mothers and their infants. Child Development; 79: 3, 547-561.