Original article

Paternal depression in the postnatal period assessed with traditional and male depression scales
Keywords
Depression Postpartum Fathers Prevalence Men Gender

Svend Aage Madsen and Tina Juhl
Abstract Background: The occurrence of postnatal depression in fathers has begun to receive attention in the international research literature. The Edinburgh Postnatal Depression Scale (EPDS) assessment tool has been validated for men. However, identification of such men has been hindered by the use of assessment tools that may not be sensitive to the particular depressive symptoms experienced by men. So far the problem of male depressive symptoms has not been included in research on men’s postnatal depressions. Methods: As part of a fatherhood research programme, the EPDS and the Gotland Male Depression Scale (GMDS) were administered to 607 fathers 6 weeks after the birth of their child. Results: 549 (90.4%) fathers were assessed for the presence of depressive symptoms. The prevalence was 5.0% with EPDS (cut-off 10) and 3.4% with GMDS (cut-off 13). While 2.1% of the fathers had scores above the cut-off on both scales, 3.1% were assessed using only the EPDS and 1.3% with only the GMDS. Conclusion: Our findings indicate that better methods for identifying men with postnatal depression need to be developed and should consist of assessment scales that also include male depressive symptoms. ß 2007 WPMH GmbH. Published by Elsevier Ireland Ltd.

Introduction
Svend Aage Madsen, PhD Department of Psychology, Play Therapy & Social Counselling, Copenhagen University Hospital, Rigshospitalet, Denmark Tina Juhl, MS Department of Psychology, Play Therapy & Social Counselling, Copenhagen University Hospital, Rigshospitalet, Denmark E-mail: svaam@rh.dk

Online 27 February 2007

The transition to parenthood has a great psychological impact on both mothers and fathers [1,2]. This has been acknowledged in relation to women for many years and many studies have focused on postnatal depression in women [3]. Postnatal depression, as measured by the Edinburgh Postnatal Depression Scale (EPDS), affects approximately 10–14% of postpartum women [4]. Some studies have shown that postnatal depression can already occur during pregnancy, in this case it is referred to as antenatal depression, and that it can also occur among fathers-to-be [5–7]. A growing number of studies on postnatal depression in women have also taken note of the father’s psychological wellbeing [8,9]. Only a few studies have had their main focus on paternal

depression [6,10]. The existing studies – most of them comprising a small sample size – report 2–24% of fathers with postpartum depression [9]. These very divergent findings reflect different methods and cut-off points, but they also indicate that this is a very new research area. It was only in 2000 that Matthey et al. [5] validated the EPDS for use in fathers postpartum. Studies have found a correlation between maternal postpartum depression and paternal postpartum depression [9]. The importance of raising the awareness of men’s postnatal depression has been emphasised by research indicating that paternal depression has a specific and detrimental effect on their children’s early behavioural and emotional development [11]. In the general population, twice as many women as men are diagnosed with depression [12]. Traditionally, it has often been hypothe-

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ß 2007 WPMH GmbH. Published by Elsevier Ireland Ltd.

Some others also give birth there by making use of the Danish right to freely choose a hospital or because of the specialisations available at the Copenhagen University Hospital.4%. the woman was asked to take the recruitment papers home for him. affective rigidity. alcohol and drug abuse are symptoms that more often occur in men suffering from depression [15–17]. e. These two arenas for recruitment were chosen to ensure participation from fathers who had not attended the prenatal courses. Of the 549 (99. The committee declared that they had no objections to our carrying out the project. Studies have shown that anger attacks. When the man did not participate. American authors in the field have used the term Masked Depression to designate the male symptoms [19]. recruited. the purpose of this study was not only to indicate the prevalence of postnatal depression in fathers in a Danish population but also to investigate whether male depressive symptoms should be included when screening for and diagnosing men with postnatal depression. Rigshospitalet. No. In total. leaving the rate of male suicides almost unaffected. A total of 468 (85. Denmark is a small country with a very homogenous population of only 51/2 million inhabitants. which showed that education of general practitioners about depressive illness resulted in a statistically significant reduction in the number of female suicides. The fathers were contacted consecutively during December 2004 through April 2005 by midwives at prenatal courses and at prenatal consultations. Examining depression related to fatherhood in first-time fathers.2%) were first time fathers.6%) answered positively. We hypothesised that integrating the GMDS into the questionnaire would make it possible to detect some fathers with possible depression who would not score above cut-off on the EPDS. Furthermore.4%) responded positively. 549 fathers returned completed questionnaires for an overall response rate of 90. 26–31.5%) fathers who returned filled out questionnaires. A further 135 were contacted via consultation and 114 (84.g. All men came from the same city area so the generalisation may be somewhat limited. These experiences led to the development of the ‘Gotland Male Depression Scale’. the 607 fathers were offered a questionnaire containing the Edinburgh Postnatal Depression Scale (EPDS) [20] and the Gotland Male Depression Scale (GMDS) [21]. All socio-economic classes are represented in the sample but data on the fathers’ employment show that the interviewed fathers had a somewhat higher education than the average population in Denmark. March 2007 27 . more studies have focused on whether men show other symptoms of depression and the concept of male depression has been discussed [3. 4. 607 men whose partner consulted the maternity ward at Copenhagen University Hospital. Condon et al concluded in 2004 that it is important to find another method to detect postnatal depression in fathers because they often show other symptoms [10]. Methods Participants In this study. Therefore. the Beck Depression Inventory and the EPDS. while 81 (14. Since the end of the 1990s. In Europe. 546 were living with the mother. Walinder & Rutz [14] proposed this syndrome following the experiences of the Gotland Study. 1. were Measures The EPDS is a questionnaire with 10 self-report items with a focus on the emotional and Vol. In a modified version. Only an insignificant number of the participating fathers were partners of mothers belonging to a special patient group. clinical work with fathers suffering from mood disorders related to parenthood indicates the importance of identifying symptoms other than those used in traditional instruments for assessing depression. The 607 participants were recruited as follows: at the courses. However. self-criticism.8%) had had children before. Six weeks after the birth of their child.Original article sised that this is due to women’s physiology for reproductive functioning [13].14]. some authors refer to these symptoms as the Male Depressive Syndrome [18]. which nearly all first-time fathers do in Denmark [2]. pp. this scale has been used in other studies of the Male Depressive Syndrome [18]. 550 men were asked to participate and 493 (89. The Danish National Committee on Biomedical Research Ethics received an application with the research protocol of the study. Mean age of the men was 32 years (range 22–57 years). Women living in the hospital’s catchment area will deliver at the Copenhagen University Hospital.

6.8% of non-depressed men are correctly classified and only 7% are misclassified. The GMDS has been validated by Zierau et al.6% of the at-risk fathers (see also Table 4). 26–31.e. parametric U test.0%)* 18 (3. As measured by the GMDS. was analysed using the Mann–Whitney non- 27 (5.4% of depressed men and 93. pp. The prevalence of depression.1% of the 18 men scoring above the cut-off on the GMDS also scored above the cut-off on the EPDS (see Fig. 3.1%.86) and internal homogeneity (Loevingers coefficient = 0. 71. 20. Internal validity. while somatic symptoms are given less importance. According to Matthey et al’s validation study [5] on 208 fathers. while 3. 549 (90. No.3%) of the 607 participating fathers had completed both the EPDS and the GMDS.5% of the participants had a score above the cut-off on either one of the scales or on both and were thus at risk for postnatal depression according to the principles laid down here (see Table 1). Results show that the median from those fathers scoring above the cut-off is significantly different from the Table 1 Fathers at risk of postnatal depression EPDS GMDS Postnatal Depression including EPDS + GMDS Completed questionnaires: *542. [21]. y529. Seven men scored above the GMDS cut-off but below the EPDS cut-off.4%) returned the questionnaire. the EPDS is both reliable and valid for fathers. The percentage of fathers who scored above the cut-offs on both scales was 2. Comparisons of the two scales show that 67. The Gotland Male Depression Scale is also a screening instrument and consists of 13 selfreport items. The results of the analysis for internal validity using the Mann–Whitney U test are presented in Table 2. while 524 (86. while according to the Gotland Male Depression Scale 39% of the patients had a probable or definite depression and should be considered for treatment with antidepressants.4% of fathers who had a cut-off score of 13 were at risk of depression. 40. Identities and differences between answers on the tests were analysed using Fisher’s exact test (2-sided) and Cohen’s kappa measurement of agreement. i. who compared it with the Major Depression Inventory in a population of male patients treated for alcohol dependency. while 61. The EPDS is a screening instrument in which a score of 13 is widely used to indicate a probable depressive disorder in women.5%)z 28 Vol. also scored above the GMDS cut-off.0% of fathers who had cut-off scores of 10 were at risk of postnatal depression.3%) and the GMDS by 529 (87.Original article cognitive characteristics of depression. measured from the mean scores on the two scales. The optimum cut-off score for this is 10 on the EPDS.1% of the 34 fathers at risk for postnatal depression. as well as the prescription of antidepressants. Procedures Risk of postnatal depression in fathers was defined as a total score of 10 on the EPDS and 13 on the GMDS.1%). As measured by the EPDS.1% were assessed using only the EPDS and 1. 4. Results Of the 607 men. A score of 13 indicates a possible depression. Use of this threshold gave an overall sensitivity of 86% and a specificity of 78% for all forms of depression [20]. Of the 27 men scoring above the cutoff on the EPDS. The EPDS has been validated for use postnatally and during pregnancy [22].7%.6% in the at-risk group scoring above the cut-off values are detected by only one of the scales. The number of men scoring above the cut-off on the EPDS but below the cut-off on the GMDS was 47. The prevalence of depression according to the Major Depression Inventory was 17%. which indicates probable depression in men. 1). Using this score. 1. z524. In all. were used as indices of validation.37). Validation of the scale shows that all women found to have definite major depression when interviewed have scored above 12 on the scale. March 2007 . The EPDS was correctly completed by 542 of the 607 fathers (89. The GMDS was shown to have an adequate internal validity made up of internal consistency (Cronbach coefficient alpha = 0.4%)y 34 (6. It was developed to improve the recognition of major depression in males by focussing on ‘male depressive symptoms’ [23].3% using only the GMDS. The GMDS should be seen as a first attempt to assess male depressive symptoms. Using caseness of depression it discriminates between distressed and non-distressed fathers. 5.

001 <0. restlessness. 1.001 <0. depressive illness.009 Mann–Whitney U test.001 <0.001 <0. low impulse control Feeling of being burnt out and empty Constant.001 <0. A comparison of the two scales using Fisher’s exact test (2-sided) is shown in Table 4. pp.001 <0.001 <0. The results (P < 0.001 <0.001 <0.001 <0.001 <0. The t-test with Cohen’s kappa measurement of agreement shows Kappa = 0. Vol. which indicates a fair to moderate but no substantial relationship.001 <0. under.0001) indicate that the responses in the two scales are related. suicide * 1 0 0 0 0 0 0 0 0 0 0 0 0 (0–3) (0–2) (0–3) (0–3) (0–2) (0–2) (0–3) (0–2) (0–2) (0–1) (0–1) (0–2) (0–3) <0. 4.001 <0. inexplicable tiredness Irritability.001 <0. so research into men’s depression related to fatherhood still has a long way to go before median of those fathers scoring below the cutoff and applies to all items of both scales.001 <0.001 0. results show that a high score on any single item of the GMDS is related to a high score on the total GMDS scale. alcoholism. An analysis of the relationship between the two median scores for the two scales is Table 2 Analysis of median values for each item EPDS Median (min-max) EPDS < 10 EPDS  10 1 1 2 2 1 2 1 1 0 0 (0–3) (0–2) (0–3) (0–3) (0–3) (1–3) (0–3) (1–3) (0–2) (0–2) P* Not being able to laugh and see the funny side of things Not looking forward with enjoyment to things Blaming oneself unnecessarily when things went wrong Being anxious or worried for no good reason Having felt scared or panicky for not very good reason Feeling things have been getting on top of one Having been so unhappy that it became difficult to sleep Having felt sad or miserable Being so unhappy that it led to crying Thoughts of harming oneself have occurred GMDS 0 0 1 1 0 0 0 0 0 0 (0–2) (0–2) (0–3) (0–3) (0–3) (0–3) (0–2) (0–2) (0–2) (0–2) <0.001 <0.49. feeling of disquiet/anxiety/displeasure Abusive behaviour. hyperactive behaviour.001 P* Median (min-max) Gotland < 13 Gotland  13 2 2 2 2 2 1 3 1 0 1 1 1 0 (1–3) (0–2) (1–3) (1–3) (1–3) (0–3) (0–3) (0–2) (0–3) (0–2) (0–3) (0–3) (0–3) Lower stress threshold Aggressiveness.or overeating Antisocial behaviour Depressive thought content Complaintiveness Hereditary loading. dissatisfaction Difficulty making ordinary everyday decisions Sleep problems In the morning especially. March 2007 29 . 26–31.001 <0.001 <0. No.001 <0.Original article presented in Table 3 and shows that scores on the single items of the GMDS are significantly related to the total score of the EPDS. Discussion Just as research on women’s postnatal depression took a long time to establish itself. Figure 1 Scatterplot of the Edinburgh Postnatal Depression Scale (EPDS) and the Gotland Male Depression Scale (GMDS) scores. Furthermore.001 <0.

0–5. that since 20.0 20 14.0–5.0) (1.0–5.0–5.00 1. The high response rates from the men in this study show that men as fathers are very interested in.5%) is still within the range of former studies using only the EPDS.0 5.0) (3. Our study shows that among the 5% of participants scoring above the cut-off on the EPDS.00 490 16 506 1.0–18.0) (1.0–9. 40.001 <0.8) (1. important.Original article Table 3 An analysis of the relationship between the median scores for the EPDS and GMDS scales Median EPDS score (25–75 percentile) Item no.0) (6. 4. This indicates that among men with postnatal depression detected using the traditional symptoms included in the EPDS.0–5. The inclusion of these symptoms has Table 4 Fisher’s exact test (2-sided) Gotland score 13+ 0.14] have shown that the cut-off values used give the best estimate of prevalence of depression at 6 weeks postpartum.0 3. the rate of prevalence (6.001 <0.5) (9. [23].0 (1.0–12.001 <0.0) (1. 26–31.5) (6.0) (5.0) (1.8–11.0–5.0–6. However. G_1 > 1 G_2 > 1 G_3 > 1 G_4 > 1 G_5 > 1 G_6 > 1 G_7 > 1 G_8 > 1 G_9 > 1 G_10 > 1 G_11 > 1 G_12 > 1 G_13 > 1 * n 475 467 459 457 456 464 429 470 470 475 475 474 449 Low score on GMDS item (1) 3. symptoms like the ones represented in GMDS are more frequent in male than in female inpatients diagnosed with depression.0 7.0) (6.0 3.0 8.3–19. When including the GMDS with male depression symptoms.001 0. The 5% prevalence rate for men’s postnatal depression using the EPDS and its traditionally accepted symptoms of depression is very much in accord with Matthey et al’s validation study [5]. it is important to consider the male-specific symptoms. since very little attention has been paid to this problem in health services or among health professionals.0 9.5% or 4000–4500 Danish men a year are at risk for postnatal depression is. As shown by Winkler et al.014 Mann–Whitney non-parametric test.0) (3.0–11.0–10.001 0. It should be noted. Besides being the first study on Danish men’s psychological problems relating to the birth of their children.00 7 11 18 497 27 524 Total not been done before in non-clinical samples or in assessing postnatal depressions.0 3.5) (6.001 <0.0 4.0 3.0 9.001 <0.0 3.0) (1.8) P* <0.7% of the men also scored above the cut-off on the GMDS.0 3.0–4. Presupposing that the GMDS is actually able to detect individuals 30 Vol.0–4.001 <0.0–4.0 2. there is consensus on definitions and before usable scales have been developed and validated.0) (1.0) (2.0 9. The instruments used in this survey are both self-report instruments and are thus not providing a clinical diagnosis of depression.0–11.0) (1.0) (1. research into the psychological aspects of men’s transition to fatherhood.001 <0. meaning that some fathers scoring below the cut-off values may suffer from depression and some scoring above may not. Therefore the results have to be seen as indicating probable depression.0–10.0–4.0) n 67 22 36 32 44 15 65 7 12 1 4 9 32 High score on GMDS item (>1) 6.0) (1.5 9. The finding that 6. this study incorporates ‘male depression’ symptoms by using the GMDS.0–5.0 3.081 0. however.0 10.5 7.6% of the at-risk fathers in the present study have a score above the cut-off value only on the GMDS and a score under the cut-off value on the EPDS.0–4.0 3. itself.0) (1. No. March 2007 .0–4.0–9. and willing to contribute to.0) (5. the validation studies for both instruments [5.00 EPDS score 10+ Total .8) (5.0 3.0 3. a considerable number are detected only with this male symptoms scale.0–10.001 <0. pp.0 (4.0 3.001 <0. 1.0) (1.

One goal should be the development of screening instruments that include both men and women with postnatal depression.Original article suffering from depression. Pickering K. one-fifth of the men with depression were detected only when the ‘male sensitive’ assessment was used. 1. Int J Ment Health 2004. HTM. Copenhagen: Hans Reitzels Forlag. Fædres tilknytning til spædbørn. Wilkinson G. [21] Zierau F. [2] Madsen SA. The identification of various kinds of depression among men who become fathers is especially important. Lind D. Kasper S. Future research should focus on developing more exact assessments of the male-specific symptoms of both general and postnatal depression. as shown by Ramchandani et al. [12] Center for Psykiatrisk Forskning. Paternal postpartum depression. [14] Walinder J. London: Gaskell. Gender-specific symptoms of depression and anger attacks. [23] Winkler D. 2000. Family structure and depressive symptoms in men preceding and following the birth of a child. Dunn JF. 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Although there is a need for more research it has been shown that it is possible to identify men with paternal depression using the two scales mentioned here. Postpartum psychiatric disorders. [10] Condon JT. [7] Kitamura T.140:111–7. Acknowledgements This research project received funding from the EU-Commission under ‘Community Framework Strategy on Gender Equality 2001–2005’.111:486–92. children of fathers with postnatal depression show signs of emotional and behavioural problems. Golding J. Francomb H. 2):S21–4. pp. Prospective study of the psychiatric disorders of childbirth. Male depression and suicide. The Gotland Male Depression Scale: a validity study in patients with alcohol use disorder.45(1):26–35. References [1] Bartlett EE. Munck H.155(6):818–23. as ‘male symptoms’ may occur in women and because many men suffer from ‘traditional’ symptoms of depression. Men and depression: clinical and empirical perspectives. Pollack WS. Pjrek E. 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