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ternal depression during this period may have similar characteristics, but data are based
HE PREVALENCE , RISK FAC -
on an emerging and currently inconsistent literature.
tors, and effects of depression
among new fathers are poorly Objective To describe point estimates and variability in rates of paternal prenatal
and postpartum depression over time and its association with maternal depression.
understood. Although a large
body of research on maternal depres- Data Sources Studies that documented depression in fathers between the first tri-
sion documents incidence rates be- mester and the first postpartum year were identified through MEDLINE, PsycINFO,
EMBASE, Google Scholar, dissertation abstracts, and reference lists for the period be-
tween 10% and 30% and negative
tween January 1980 and October 2009.
family and child developmental out-
comes,1-3 paternal prenatal and post- Study Selection Studies that reported identified cases within the selected time frame
were included, yielding a total of 43 studies involving 28 004 participants after dupli-
partum depression has received little at-
cate reports and data were excluded.
tention from researchers and clinicians.4
The emerging literature on paternal de- Data Extraction Information on rates of paternal and maternal depression, as well
pression suggests that, like their ma- as reported paternal-maternal depressive correlations, was extracted independently
by 2 raters. Effect sizes were calculated using logits, which were back-transformed and
ternal counterparts, fathers are at in- reported as proportions. Random-effects models of event rates were used because of
creased risk of depression in the significant heterogeneity. Moderator analyses included timing, measurement method,
postpartum 5 and gestational peri- and study location. Study quality ratings were calculated and used for sensitivity analy-
ods.6-8 Moreover, several studies have sis. Publication bias was evaluated with funnel plots and the Egger method.
now documented negative child out- Data Synthesis Substantial heterogeneity was observed among rates of paternal
comes associated with paternal prena- depression, with a meta-estimate of 10.4% (95% confidence interval [CI], 8.5%-
tal and postpartum depression.9,10 12.7%). Higher rates of depression were reported during the 3- to 6-month postpar-
Although recent literature has ad- tum period (25.6%; 95% CI, 17.3%-36.1%). The correlation between paternal and
dressed this phenomenon, studies in pa- maternal depression was positive and moderate in size (r = 0.308; 95% CI, 0.228-
ternal prenatal and postpartum depres- 0.384). No evidence of significant publication bias was detected.
sion are troubled by inconsistent Conclusions Prenatal and postpartum depression was evident in about 10% of men
methods, clinical heterogeneity, and in the reviewed studies and was relatively higher in the 3- to 6-month postpartum
prevalence estimates that vary consid- period. Paternal depression also showed a moderate positive correlation with mater-
erably.5,7,11-20 To date, only 2 reviews on nal depression.
prenatal and postpartum depression in JAMA. 2010;303(19):1961-1969 www.jama.com
©2010 American Medical Association. All rights reserved. (Reprinted) JAMA, May 19, 2010—Vol 303, No. 19 1961
of paternal depression were affected by eral Health Questionnaire30). We ex- quality ratings in observational re-
methodological factors such as mea- cluded studies that selected fathers search is lacking, we adopted the ap-
surement method, study location, and based on established maternal mental proach of Stroup et al23 of broadly in-
sample risk status. health problems because this could bias cluding studies and using sensitivity
meta-analytic estimates. Also, because analysis to determine incremental ef-
METHODS the identified studies of teen fathers fects of lower-quality studies.
Search Strategy were characterized by significant eco-
We used 3 methods to identify studies nomic and social stressors, only stud- Effect Size and Statistical Analysis
for this meta-analysis. First, we used the ies of fathers aged 18 years or older were Primary Outcome. The primary out-
reference lists of the most relevant re- included. come was the point prevalence rate of
views.5,11 Next, we searched MEDLINE, paternal depression, defined as the
PsycINFO, Dissertation Abstracts In- Data Abstraction number of cases divided by the total
ternational, EMBASE, and Google and Quality Assessment number of study participants. We coded
Scholar using the search terms depres- The 2 authors used a standardized cod- these into both simple proportional
sion, paternal, father, postnatal, postpar- ing manual (available from the au- effect sizes (by dividing the number of
tum, prenatal, antenatal, and perinatal. thors on request) to extract the follow- cases by the sample size) and logit units,
Finally, we used the “ancestry ap- ing data from articles: author names, as a direct transformation of these pro-
proach,”21 which involves consulting publication year, sample size, period of portions. In this context, the logit trans-
the reference lists of retrieved articles assessment, study sample risk (0 or 1; formation was used to form an un-
to find earlier relevant studies. Be- high risk coded when a study denoted bounded (in contrast to the 0-to-1
cause of the emergent nature of this this clearly, including medically as- bounded nature of proportions) esti-
body of observational research litera- sisted pregnancies and infants with mate to facilitate moderator analy-
ture, an inclusive approach to study se- feeding, sleeping, or crying prob- sis.31 After analysis, logit units were
lection was used.22,23 Therefore, we in- lems), location, sample size, response back-transformed to proportions for the
cluded all relevant and accessible rate, number of fathers identified as de- purposes of reporting.
journal articles, dissertations, and book pressed, number of mothers identified Secondary Outcomes. Secondary
chapters that were produced between as depressed (when assessed), and cor- outcomes included rates of depres-
January 1980 and October 2009 that as- relation between maternal and pater- sion in female partners, which we coded
sessed paternal depression during preg- nal depressive symptoms. The coding as raw proportions and logit units, and
nancy, the first postpartum year, or manual was developed a priori and standardized zero-order correlations be-
both. modified after use in several studies. tween paternal and maternal depres-
Coding was done independently then sive symptoms (when measured with
Study Selection aggregated, with disagreements re- a continuous or ordinal scale).
Studies that reported an estimated solved through discussion and con- All major analyses were conducted
number of depression cases among sensus. Although quality assessment with Comprehensive Meta-Analysis,
identified fathers were included. This can be reliably conducted in meta- version 2.0. 32 In general, random-
resulted in the exclusion of several analyses of experimental studies, its use effects models are argued to better ad-
studies that reported mean scores for in observational research is controver- dress heterogeneity between studies and
symptom severity because the exact sial, with no clear consensus on rating study populations, allowing for greater
number of cases could not be clearly de- methods or their appropriate use in flexibility in parsing effect size variabil-
termined. Several articles9,10,24-27 used analysis. As such, we used a simple ob- ity. Moreover, they are less influenced
data from common databases and were jective rating system (based on the by extreme variations in sample size.22
excluded to avoid duplication of data. meta-analysis of similar data by Ben- Because studies in this meta-analysis are
Several studies measured depression on nett et al2) that coded studies on a scale characterized by heterogeneity and
multiple occasions. In these cases, 1 of 0 to 10, assigning 2 points each for highly variable sample sizes, random-
depression measure per time period sampling method (systematic or prob- effects models were used. Heteroge-
was selected based on these priorities: ability vs convenience or not re- neity among study point estimates was
(1) structured interviews; (2) mea- ported), presence of clearly stated in- assessed with the Q statistic, with mag-
sures with demonstrated generality in clusion criteria, racial/ethnic diversity nitude of heterogeneity being evalu-
men (eg, Beck Depression Inven- (!20% minority), educational diver- ated with the I 2 index. 31 When re-
tory28) vs adaptations of maternal mea- sity ("80% at 1 educational level), and ported, all confidence intervals (CIs)
sures (eg, Edinburgh Postnatal Depres- response rate (reported at !60%). Stud- reflect a 95% criterion.
sion Scale29); and (3) measures with ies that did not report these method- We examined the following deter-
greater specificity for depression (eg, ological issues received lower scores. minants of primary and secondary out-
Beck Depression Inventory28 vs Gen- Because evidence on the validity of comes: period of measurement, risk sta-
1962 JAMA, May 19, 2010—Vol 303, No. 19 (Reprinted) ©2010 American Medical Association. All rights reserved.
©2010 American Medical Association. All rights reserved. (Reprinted) JAMA, May 19, 2010—Vol 303, No. 19 1965
suggest direction of causal influence. Overall across all periods 0.10 (0.08-0.13)
Test for heterogeneity: I 2 = 94.91; P<.001
Studies that speak to direction of effect
0.00 0.30 0.60
are of great interest, particularly for their Event Rate (95% CI)
implications for screening and preven-
tion, but strong evidence of this is not Overall effects were calculated through random-effects model estimates, with separate calculations for overall
effects within each period and across all periods. Effect sizes were calculated via a logit transformation of rates
yet available. (number of reported cases divided by the sample size), which were back-transformed to proportions after es-
Our study has several limitations. timates and standard errors were computed. Studies are stratified by period of assessment. For studies that
First, because studies used variable assessed depression at multiple time points, only the earliest estimate is reported. Data marker size corre-
sponds to study sample size.
methods of measuring and reporting de-
©2010 American Medical Association. All rights reserved. (Reprinted) JAMA, May 19, 2010—Vol 303, No. 19 1967
pression in different time periods, time tion between paternal and maternal ALSPAC Study Team. Paternal depression in the post-
natal period and child development: a prospective
frame–specific prevalence cannot be depression also suggests a screening population study. Lancet. 2005;365(9478):2201-
clearly established, limiting interpre- rubric 73 —depression in one parent 2205.
10. Paulson JF, Keefe HA, Leiferman JA. Early paren-
tation to the rate of depression ob- should prompt clinical attention to tal depression and child language development. J Child
served at that point in time. Also, since the other. Likewise, prevention and Psychol Psychiatry. 2009;50(3):254-262.
point estimates are drawn from a pool intervention efforts for depression in 11. Schumacher M, Zubaran C, White G. Bringing
birth-related paternal depression to the fore. Women
of heterogeneous studies, many of parents might be focused on the Birth. 2008;21(2):65-70.
which did not use strong population- couple and family rather than the 12. Leathers SJ, Kelley MA. Unintended pregnancy
and depressive symptoms among first-time mothers
based sampling methods, there is a po- individual. and fathers. Am J Orthopsychiatry. 2000;70(4):
tential of bias in our results from stud- Future research in this area should 523-531.
13. Hjelmstedt A, Collins A. Psychological function-
ies’ methodological weaknesses. These focus on parents together to examine ing and predictors of father-infant relationship in IVF
may not have been adequately ac- the onset and joint course of depres- fathers and controls. Scand J Caring Sci. 2008;
counted for by our simplified method sion in new parents. This may in- 22(1):72-78.
14. Fawcett J, York R. Spouses’ physical and psycho-
of quality rating. The method of iden- crease our capacity for early identifi- logical symptoms during pregnancy and the
tifying depressed cases was highly vari- cation of parental depression, add postpartum. Nurs Res. 1986;35(3):144-148.
15. Madsen SA, Juhl T. Paternal depression in the post-
able across studies, thereby limiting the leverage for prevention and treat- natal period assessed with traditional and male de-
specificity of our primary outcome. ment, and increase the understanding pression scales. J Mens Health Gend. 2007;4(1):
However, this variability in case iden- of how parental depression conveys risk 26-31.
16. Bronte-Tinkew J, Moore KA, Matthews G, Carrano
tification accurately reflects inconsis- to infants and young children. J. Symptoms of major depression in a sample of fa-
tencies in both applied and basic re- Author Contributions: Dr Paulson had full access to
thers of infants: sociodemographic correlates and links
to father involvement. J Fam Issues. 2007;28(1):
search into prenatal and postpartum all of the data in the study and takes responsibility for 61-99.
depression. 5 Removing relatively the integrity of the data and the accuracy of the data 17. Areias MEG, Kumar R, Barros H, Figueiredo E. Com-
analysis. parative incidence of depression in women and men,
weaker studies in sensitivity analysis left Study concept and design: Paulson. during pregnancy and after childbirth: validation of
effects essentially unchanged. We did Acquisition of data: Paulson, Bazemore. the Edinburgh Postnatal Depression Scale in Portu-
Analysis and interpretation of data: Paulson, Bazemore. guese mothers. Br J Psychiatry. 1996;169(1):30-
not find substantial evidence of publi- Drafting of the manuscript: Paulson, Bazemore. 35.
cation bias in this area, and fail-safe Critical revision of the manuscript for important in- 18. Matthey S, Barnett B, Howie P, Kavanagh DJ. Di-
tellectual content: Paulson, Bazemore.
analysis suggested that our findings are Statistical analysis: Paulson, Bazemore.
agnosing postpartum depression in mothers and fa-
thers: whatever happened to anxiety? J Affect Disord.
robust to unpublished null findings. Administrative, technical, or material support: Paulson, 2003;74(2):139-147.
With these limitations in mind, this Bazemore. 19. Ballard CG, Davis R, Cullen PC, Mohan RN, Dean
Study supervision: Paulson. C. Prevalence of postnatal psychiatric morbidity in
meta-analysis allows us to draw sev- Financial Disclosures: None reported. mothers and fathers. Br J Psychiatry. 1994;164
eral conclusions regarding paternal (6):782-788.
prenatal and postpartum depression. 20. Matthey S, Barnett B, Ungerer J, Waters B. Pa-
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©2010 American Medical Association. All rights reserved. (Reprinted) JAMA, May 19, 2010—Vol 303, No. 19 1969