Scandinavian Journal of Psychology, 2017 DOI: 10.1111/sjop.

12396

Development and Aging

Symptoms of depression in Swedish fathers in the postnatal period
and development of a screening tool
ELIA PSOUNI, €
JOHAN AGEBJORN and HANNE LINDER
Department of Psychology, Lund University, Sweden

Psouni, E., Agebj€orn, J. & Linder, H. (2017). Symptoms of depression in Swedish fathers in the postnatal period and development of a screening tool.
Scandinavian Journal of Psychology.

Methods for detecting depression in fathers after the birth of their child are scarce. The Edinburgh Postnatal Depression Scale (EPDS), used to screen
mothers for postpartum depression (PPD), lacks somatization and externalizing items. This potentially decreases its sensitivity in detecting depression in
fathers, as many men actually express depression with somatization or externalizing symptoms. The present study assessed depressive symptoms in fathers
of children 0–18 months old, and evaluated whether addressing both typical depression and externalizing, so-called “depressive equivalent” symptoms,
might be more suitable for such assessment. The Beck Depression Inventory-II (BDI-II), EPDS, and Gotland Male Depression Scale (GMDS) were
responded to by 447 Swedish fathers online. Among participants, 27% reported depressive symptoms above the BDI-II cut-off suggestive of depression.
Most fathers reported both traditional and depressive equivalent symptoms and a subgroup expressed exclusively depressive equivalent symptoms.
Consistently, a scale combining items from the EPDS and GMDS showed higher sensitivity than the EPDS alone in identifying fathers with elevated
depressive symptoms, at equal levels of specificity. Our findings suggest that a combination of EPDS and depressive equivalent symptom items results in a
more suitable instrument for screening for depression in fathers during the postnatal period.
Key words: Depression, postpartum depression, fathers, male depression, screening, EPDS.
Elia Psouni, Department of Psychology, Lund University PO Box 213, Lund SE 221 00, Sweden. E-mail: elia.psouni@psy.lu.se

INTRODUCTION than the prevalence of maternal PPD (Gavin, Gaynes, Lohr,

The period after the birth of a child poses challenges to fathers’
wellbeing, presenting increased difficulties in balancing
employment commitments and personal needs next to taking care
of a newborn and (often) other children, while supporting a
partner who is also facing increased demands (deMontigny &
Lacharite, 2004; Kim & Swain, 2007). Men often report this
period to be stressful, characterized by exhaustion and mixed
positive and negative feelings (Condon, 2006). Faced with the
struggles of increased demands, many fathers feel helpless,
anxious, and irritable (Massoudi, Hwang & Wickberg, 2013).
Having to relocate their mental resources to infant care and to
coping with changes in family roles and in the partner
relationship renders many parents in the postnatal period
vulnerable mentally (Edhborg, Matthiesen, Lundh & Widstr€ om,
2005; Ramchandani, Stein, O’Connor, Heron, Murray & Evans,
2008).
Indeed, evidence has been presented over the past decade that
many men experience depressive symptoms during the postnatal
period (Goodman, 2004; Paulson & Bazemore, 2010; Cameron,
Sedov & Tomfohr-Madsen, 2016), sometimes termed paternal
postpartum depression. Postpartum depression (PPD) is defined
as a condition of depressive symptoms with an onset in the
weeks/months directly before and after childbirth (DSM-5:
American Psychiatric Association, 2013), thus mainly linked to
birth-giving and mothers. The term paternal postnatal depression
refers to depressive symptoms in fathers during the first postnatal
year. Prevalences of about 10% have been reported (Bergstr€ om,
2013; Paulson & Bazemore, 2010), the latest meta-analytic
estimate being 8.4% (Cameron et al., 2016), somewhat lower
Meltzer-Brody, Gartlehner & Swinson, 2005; O’Hara & McCabe,
2013). In Sweden, 6.3% of fathers in a general population had
burdening depressive symptoms at 3 months postnatally
(Massoudi, 2013), but higher rates are reported elsewhere for the
period 3–6 months postnatally (25.6%: Paulson & Bazemore,
2010). Notably, meta-analytic data indicate unchanged
prevalences over the entire first postnatal year (Cameron et al.,
2016). Evidently, prevalences for paternal postnatal depression in
the literature vary considerably, conceivably due to a lack of
uniform assessment for paternal depression, and no consensus
regarding the time period to be considered, or whether minor
depression, which DSM-IV (American Psychiatric Association,
2000) defined as presence of only few symptom-areas of
depression, should be included. It is also unclear whether reported
prevalences concern the entire range from severe to mild (DSM-5:
American Psychiatric Association, 2013) major depression in
fathers.
The negative consequences of paternal postnatal depression for
the entire family are nevertheless consensually recognized in the
literature. Depressed fathers report lower levels of affection and
relationship satisfaction than non-depressed fathers, also after
controlling for maternal PPD (Ramchandani, Psychogiou, Vlachos
et al., 2011), while their parenting behavior is compromised
(Wilson & Durbin, 2010). For example, fathers with postnatal
depression engage less in interaction with their infants (Sethna,
Murray, Netsi, Psychogiou & Ramchandani, 2015) and in
activities such as reading or singing to them (Paulson, Dauber &
Leiferman, 2006). Paternal depression may impact on the child’s
development independently of the impact from maternal PPD, for
instance in areas such as externalizing behavioral problems at age

© 2017 Scandinavian Psychological Associations and John Wiley & Sons Ltd
2 E. Psouni et al.
1 year (Ramchandani, Domoney, Sethna, Psychogiou, Vlachos &
Murray, 2013) and increased behavioral problems among boys at
ages 3–5 years (Ramchandani, Stein, Evans & O0 Connor, 2005;
Ramchandani et al., 2008). Importantly, associations with
negative parenting behaviors are also evident when including
milder states of paternal depression (Letourneau, Dennis, Benzies
et al., 2012; Paulson et al., 2006; Wilson & Durbin, 2010).
Paternal postnatal depression has been associated with
depressive symptoms prenatally (Matthey, Barnett, Ungerer &
Waters, 2000), a personal history of depression (Wee, Pier,
Milgrom, Richardson, Fisher & Skouteris, 2013), higher
neuroticism and introversion scores (Dudley, Roy, Kelk &
Bernard, 2001), panic or anxiety disorder (Matthey, Barnett,
Kavanagh & Howie, 2001), but also lower educational level
(Deater-Deckard, Pickering, Dunn & Golding, 1998), lower
household income (Bergstr€om, 2013) and unemployment (Edward,
Castle, Mills, Davis & Casey, 2015; Matthey et al., 2000).
Perceived mismatch between expectations and reality of
parenthood and poor social functioning are also associated with
paternal postnatal depression (Edward et al., 2015), as is lower
satisfaction, lower social support, and higher conflict in the couple
relationship (Don & Mickelson, 2012; Giallo, Esposito, Cooklin,
Christensen & Nicholson, 2014; Gutierrez-Galve, Stein,
Hanington, Heron & Ramchandani, 2015; Wee, Skouteris, Pier,
Richardson & Milgrom, 2011). However, the strongest correlate of
paternal postnatal depression is maternal PPD (Escriba-Ag€ uir &
Artazcoz, 2011; Goodman, 2004; Ramchandani et al., 2011),
suggesting substantial risk of many infants growing up with two
affected parents (Letourneau, Duffett-Leger, Dennis, Stewart &
Tryphonopoulos, 2011). Potential consequences on child
development when both parents are depressed are stronger,
compared to when one parent is affected (Brennan, Hammen, Katz
& Le Brocque, 2002; Letourneau et al., 2012), since the buffering
role of an unaffected parent is lost (Mezulis, Hyde & Clark, 2004).
Identifying fathers burdened by depressive symptoms
postnatally is thus essential not least from the perspective of the
child, yet with few exceptions fathers are not systematically asked
about their feelings during the postnatal period. In a Swedish
survey among 339 nurses, 89% reported that they seldom noticed
if a father was distressed (Massoudi, 2013), and paternal postnatal
depression was not even mentioned in a recent Swedish report
about PPD (SBU, 2014). Thus, the focus is still almost
exclusively on the mental health of mothers, despite norms about
gender equality and increasing numbers of fathers actively
engaging in parenting, which also increases the impact of the
father’s parental behaviors on child outcomes. Structured,
sensitive methods for assessing depressive symptoms in fathers
are also necessary as men seldom seek help spontaneously for
mental health concerns (Boman & Walker, 2010; Cheung &
Dewa, 2007; Diaz-Granados, Georgiades & Boyle, 2010;
Mahalik, Levi-Minzi & Walker, 2007; Seidler, Dawes, Rice,
Oliffe & Dhillon, 2016). In Massoudi’s (2013) study, fewer than
50% of fathers with depressive symptoms stated that they might
seek professional help.
Indeed, depression rates in men in the general population are
nearly half those of women (World Health Organization, 2008).
This consistent observation was earlier construed as female
susceptibility due to hormonal states (Bebbington, 1998),
© 2017 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol (2017)
emotionality, or a stronger orientation towards people causing
exposure to difficulties involving other people (Bebbington, 1998;
Connellan, Baron-Cohen, Wheelwright, Batki & Ahluwalia, 2000;
Rice, Fallon, Aucote & M€ oller-Leimk€
uhler, 2013), though none
of these hypotheses is clearly empirically supported. However,
besides evidence that men are underreporting their depressive
symptoms (Seidler et al., 2016), it has been suggested that they
may express depression through externalizing behaviors not
recognized by healthcare professionals as depressive symptoms
(Rutz, 1996), or through other less obvious symptoms, leading to
diagnostic misses, misdiagnosis or rejection.
Indeed, besides social withdrawal, avoidance, affective rigidity,
and irritability, which are commonly associated with depression in
both men and women, research indicates that anger attacks and
acting out, acting abusively towards others, abusing alcohol/drugs,
risk-taking behavior and physical distress expressed through
somatization, are more common expressions of depression among
men while stress, rumination, sleep problems, loss of interest,
feelings of shame and guilt are more common expressions of
depression among women (Danielsson & Johansson, 2005;
Martin, Neighbors & Griffith, 2013; Kim & Swain, 2007;
Rodgers, Holtforth, M€ uller, Hengartner, R€
ossler & Ajdacic-Gross,
2014; Schumacher, Zubaran & White, 2008). These differences
have been attributed to male testosterone levels (Sigurdsson,
Palsson, Aevarsson, Olafsdottir & Johannsson, 2015), but also to
socialization processes resulting in men suppressing symptoms
associated with signaling weakness (Seidler et al., 2016). One
measure to capture these externalizing “depressive equivalents”
(Rutz, W alinder, von Knorring, Rihmer & Pihlgren, 1997) is the
Gotland Male Depression Scale (GMDS, W alinder & Rutz,
2001). The GMDS has been criticized for weak factor structure
stability (Rice et al., 2013), but is to our knowledge the only
scale empirically validated for capturing depressive equivalents
(Zierau, Bille, Rutz & Bech, 2002; Chu, Chen, Jiang et al., 2014;
Sigurdsson et al., 2015).
The Edinburgh Postnatal Depression Scale (EPDS: Cox,
Holden & Sagovsky, 1987), most common self-report measure for
postnatal depression in mothers and fathers, focuses nevertheless
solely on feelings of sadness and anxiety, excluding somatic
symptoms of depression that commonly arise due to physiological
changes after childbirth, or externalizing depressive equivalents.
There is extensive evidence of validity of the EPDS-score as
screening index for maternal PPD (Gibson, McKenzie-McHarg,
Shakespeare, Price & Gray, 2009), and some evidence of validity
for detecting postnatal depression in fathers (Matthey, Barnett,
Kavanagh & Howie, 2001), using lower cut-off scores to
accommodate for men’s hypothesized restrictedness in expressing
negative emotion (e.g. Edmondson, Psychogiou, Vlachos, Netsi &
Ramchandani, 2010; Lai, Tang, Lee, Yip & Chung, 2010; Tran,
Tran & Fisher, 2012). But while with a cut-off of 12, a study in
Sweden found 100% sensitivity (CI 66%–100%) for major
depression in fathers (Massoudi et al., 2013), there are indications
that the EPDS may not be as sensitive for detecting mild paternal
depression. For example, with cut-offs of 9 and 11, sensitivity for
mild depression (based on the DSM-IV) was 66% and 34%,
respectively (Massoudi et al., 2013). The evidence that also mild
depression in fathers is associated with more negative parenting
behaviors (Letourneau et al., 2012; Paulson et al., 2006; Wilson
Scand J Psychol (2017)
& Durbin, 2010) motivates an adaptation of the EPDS so that it
can sensitively capture milder forms of paternal depression.
Notably, when fathers were assessed with EPDS and GMDS
together, 20% scored above cut-off only on the GMDS (Madsen
& Juhl, 2007), suggesting that it might be advisable to adapt the
EPDS in fathers so that it also addresses externalizing, depressive
equivalent symptoms.
THE PRESENT STUDY
Given the absence of measures for postnatal depression
specifically targeting fathers, the first aim of the present study was
to investigate whether depressive symptoms in fathers postnatally
comprise both typical depressive symptoms and externalizing,
depressive equivalents. Based on previous findings on depression
in men, and in fathers postnatally (Madsen & Juhl, 2007), we
hypothesized that while many fathers would express both typical
depressive symptoms and depressive equivalents, some fathers
would only express depressive equivalents. As a first step in
identifying appropriate self-report items for assessing depressive
symptoms in fathers postnatally, a second aim was to test the
hypothesis that the addition to the EPDS of items addressing
depressive equivalents would result in increased sensitivity in
detecting fathers with elevated, burdening depressive symptoms,
using as reference Beck Depression Inventory II (BDI-II: Beck,
Steer & Brown, 1996), a DSM-5 compatible measure of
depression.
Postnatal depression has a later onset among fathers than
among mothers (Edward et al., 2015), with similar prevalences
over the entire first year (Cameron et al., 2016; Goodman, 2004).
Considering also evidence that prevalence of paternal depression
is higher at 12 months, compared to 3 months, postnatally
(Escriba-Ag€uir & Artazcoz, 2011), it cannot be excluded that
depressive symptoms in fathers may surface after 12 months
postnatally. Thus, in the present study we included paternal
reports of common depressive symptoms and depressive
equivalents in the period up to 18 months postnatally, instead of
the commonly used period of 12 months, suspecting that we
would recover similar prevalences among fathers with children
12-18 months old as among fathers of younger infants.
METHOD
Participants
In total, 447 fathers completed an online survey consisting of self-
report measures of depression and demographic variables, and
438 cases were available for analysis after removing cases with
(over 5%) missing data. Most common age among participating
fathers was 30–34 years (M = 34.1, SD = 6.7). 275 fathers
(62.8%) had one child, 118 (26.9%) had two and 45 (10.3%) had
three or more children. Most fathers (n = 333, 76%) had post-
high-school education, indicating education bias among
participants (compared to the 40% rate in the corresponding age
group in the general population: Statistics Sweden, 2014). Most
were employed (n = 385, 88%), with mean monthly gross income
corresponding to 3,400 euro (median 3,200 euro) which,
compared to the mean salary for Swedish men in 2013 – 2,600
© 2017 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Measuring postnatal depressive symptoms in fathers 3
euro (median 2,430 euro: Statistics Sweden, 2015), indicates an
overrepresentation of well-paid fathers, consistent with the higher
education level in our sample. The age of participating fathers’
youngest children was evenly distributed across the range 0–18
months. At the time of participation, 123 fathers (28%) were on
parental leave and 140 (32%) had previously been on parental
leave. The partners of 92 fathers (21%) had received or were
scheduled to receive professional help for their depressive
symptoms. During the 2 years preceding the study, 18 fathers
(4%) separated, 39 (9%) suffered illness or trauma and 96 (22%)
experienced illness or death among family and close friends.
Materials
Depression scales. Aligning with the DSM-IV and DSM-5
diagnostic criteria, the BDI-II is the most broadly used self-report
measure of depression. Its 21 items, responded to on a four-point
Likert scale, address psychological symptoms such as sadness
(e.g., “I feel sad all the time”), pessimism (e.g., “I do not expect
things to work out for me”), and suicidal thoughts (e.g., “I would
kill myself if I had the chance”), along with physical symptoms
such as fatigue (e.g., “I am too tired or fatigued to do most of the
things I used to do”), loss of energy (e.g., “I don’t have enough
energy to do anything”), and loss of libido (e.g., “I have lost
interest in sex completely”). BDI-II is reliable across gender and
ethnicity (Cronbach’s alpha = 0.9 based on around one hundred
studies: Wang & Gorenstein, 2013; Whisman, Judd, Whiteford &
Gelhorn, 2012) and with good diagnostic validity (e.g. Hobkirk,
Starosta, De Leo et al., 2015; Wu & Huang, 2010). The BDI-II
has also been validated for use with mothers pre- and postpartum
(e.g. Boyd, Le & Somberg, 2005; Brodey, Goodman, Baldasaro,
et al., 2016; Tandon, Cluxton-Keller, Leis & Perry, 2012).
Although high scores on the BDI-II do not suffice for diagnosing
depression in clinical practice, it was used here as reference
measure for suspected depression. In the present sample, the BDI-
II demonstrated very high reliability (Cronbach’s alpha = 0.95).
Confirmatory factor analysis (maximum likelihood) demonstrated
good fit for the full measurement model based on 21 observed
indicators and a single latent variable (v2(189) = 663.36,
p < 0.0001, CFI = 0.88, TLI = 0.87, RMSEA = 0.07, RMR =
0.025). All indicators loaded significantly on to the latent variable
(p < 0.0001).
The EPDS (Cox et al., 1987; Swedish translation, Wickberg &
Hwang, 1996) is a 10-item self-report questionnaire for screening
depression in women after childbirth. Items focus on depressed
mood, e.g. “I have felt sad or miserable”, with responses on a
four-point Likert-type scale. Even though the EPDS was
originally designed for use in women, Matthey (2001)
demonstrated its reliability when used with men (Cronbach’s
alpha = 0.81, Spearman-Brown split-half reliability = 0.78), and
evidence for construct validity (correlation with a Depression
scale, r = 0.62). The Swedish version of the EPDS is valid for
screening for PPD among mothers (B agedahl-Strindlund &
Monsen B€ orjesson, 1998; Wickberg & Hwang, 1996) and has
shown validity when used with Swedish fathers, based on
comparisons with a diagnostic interview, and internal consistency
with a Cronbach’s alpha of 0.81 (Massoudi et al., 2013). Internal
consistency in the present study was Cronbach’s alpha = 0.85.
4 E. Psouni et al. Scand J Psychol (2017)

An EPDS cut-off ≥ 9 was used as suggestive of mild depression, authors for guidance if they felt they needed to. Arrangements
in line with two large validation studies that considered both mild had been made for quick referrals to respective healthcare services
and severe major depression (Matthey et al., 2001; Massoudi in such a case. Some participants contacted the authors with
et al., 2013). A separate count was made of fathers with an EPDS further enquiries about the study but none expressed interest in
score ≥ 12, taken to suggest severe depression, in line with the establishing a therapeutic contact.
recommendation of the Swedish validation study of EPDS with
fathers (Massoudi et al., 2013).
The GMDS (W alinder & Rutz, 2001) is a 13-item self-report Statistical analysis
measure of male depression symptoms. The 7-item distress Data was analyzed using IBM SPSS Statistics, version 22.
subscale, with items concerning acting impulsively or having a Dichotomous variables based on scale cut-offs were created from
decreased stress tolerance (e.g. I/others have noticed that I am each depression scale. Cross-tabulations of these variables were
more aggressive, outward reacting, difficulties keeping self- performed in order to test whether the scales converged in
control), was used to capture depressive equivalents. Responses detecting suspicion for depression. To identify an optimal set
are on a four-point Likert-type scale. In a validation study by among the EPDS and GMDS items for evaluating suspicion of
Zierau et al. (2002), the measure showed acceptable validity, in depression in fathers postnatally, the database was split half and
relation to the Major Depression Inventory, and reliability exploratory factor analysis (maximum likelihood) was carried out
(Cronbach’s alpha of 0.86 for the whole scale and 0.78 for the on the first half (n = 220). After employing a combination of
distress subscale). Internal consistency in the present study was common techniques for item reduction, confirmatory factor
Cronbach’s alpha = 0.84. For creating a dichotomous variable, a analysis (maximum likelihood) was employed on the second half
cut-off value for “probable”, as opposed to “definite”, depression of the database (n = 218). Finally, sensitivity and specificity
was selected (Zierau et al., 2002). analyses (using ROC curves) were carried out comparing the
The timeframe for experienced symptoms was changed from EPDS to the newly obtained item set, using the BDI-II indication
seven days to two weeks in the EPDS, and from four to two of at least mild depression as reference. Sensitivity indicates the
weeks in the GMDS, for consistency with the timeframe used in proportion of respondents for which the BDI-II indicates
the reference measure (BDI-II) and the DSM-definition of suspicion of mild depression, who are also correctly identified by
depressive disorder. This adjustment was also deemed necessary the focus measure (extend to which the measure does not result in
in order to not confuse the participants, and to be able to combine false negatives). Specificity measures the proportion of non-
different items into a new scale with one consistent timeframe. sufferers according to the focus measure that are also identified as
such also according to the BDI-II (extend to which the measure
Background information. Demographic and circumstantial does not result in false positives).
variables such as stressful life events were examined. Questions
concerned age of the father and the child, occupation, educational
level, income, number of children, whether the father and/or his RESULTS
partner had previously, and at the time of the study, received
professional help for mental health problems, and whether the Depressive symptoms in the sample
father was or had been on parental leave. Table 1 presents means, standard deviations, and cut-off values
for depressive symptoms suggesting mild depression (all
measures), moderate and severe depression for BDI-II, and severe
Procedure
depression for EPDS.
Upon approval by a regional ethical review board, an internet About 28% of fathers (n = 122) reported symptoms above the
address was created for the survey. Posters presenting the study BDI-II ≥ 14 cut-off for mild depression. Of those, 61 (13.9%)
link, together with contact information, were placed on reported symptoms above the BDI-II ≥ 20 cut-off for moderate
noticeboards on child health and family centers and open depression. Table 2 presents demographic and situational
preschools, and posted on Swedish internet forums about variables separately for men scoring above and below the cut-off
parenthood, psychological health, exercise and fitness, cars and for mild depression, respectively. There was neither an age
motorcycles, games and computers/multimedia. No remuneration
was offered for participation. Data was collected over a period of
4 months. Based on piloting work, the survey took about 20 Table 1. Properties of and descriptive statistics for the depression scales
minutes to complete. At the survey opening page, participants
received information concerning the type of questions included n (%) over
Scale a M SD Cut–off cut–off
and concerning procedures for securing anonymity. Data
collection was entirely anonymous: participants could neither be BDI-II 0.95 10.20 8.70 ≥ 14 (mild/major) 122 (27.85%)
identified nor contacted during or after participation. As a ≥ 20 (moderate/major) 61 (13.93%)
necessity when implementing such anonymity policy, it was also ≥ 29 (severe/major) 15 (3.10%)
made clear to participants that they could not be contacted for EPDS 0.85 7.30 4.90 ≥ 9 (minor) 157 (35.84%)
≥ 12 (major) 86 (19.63%)
guidance and support, irrespective of how they answered the
GMDS- 0.84 4.00 3.70 ≥7 93 (21.23%)
survey’s questions. Instead, participants were urged with text on distress
the landing page of the survey to not hesitate to contact the

© 2017 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol (2017) Measuring postnatal depressive symptoms in fathers 5

Table 2. Characteristics of fathers below and above the BDI–II cut–off ≥14 for mild depression

BDI–II <14 (n = 316) BDI–II ≥14 (n = 122)

Father characteristics Count Prop. 95% CI Count Prop. 95% CI

Father age
20–29 yrs 59 0.19 0.15 0.22 31 0.25 0.18 0.32
30–39 yrs 216 0.68 0.63 0.73 78 0.64 0.54 0.71
40–49 yrs 41 0.13 0.09 0.15 13 0.11 0.06 0.14
Father education
≤ 12 years full–time 73 0.23 0.19 0.26 34 0.28 0.19 0.33
12–15 years full–time 99 0.31 0.26 0.35 46 0.38 0.29 0.45
≥ 16 years full–time 144 0.46 0.40 0.50 42 0.34 0.26 0.42
# children
1 213 0.67 0.62 0.72 62 0.51 0.42 0.59
2 or more 103 0.33 0.27 0.36 60 0.49 0.43 0.60
Youngest child’s age
0–6 months 143 0.46 0.40 0.51 50 0.41 0.32 0.49
7–12 moths 93 0.29 0.24 0.33 34 0.28 0.20 0.34
13–18 months 80 0.25 0.21 0.29 38 0.31 0.22 0.37
Divorced?
yes 9 0.03 0.01 0.04 9 0.07 0.03 0.10
no 307 0.97 0.95 0.99 113 0.93 0.86 0.96
Own illness?
yes 21 0.07 0.04 0.08 18 0.15 0.09 0.19
no 295 0.93 0.90 0.96 104 0.85 0.78 0.91
Family member’s illness?
yes 69 0.22 0.17 0.25 27 0.22 0.15 0.28
no 247 0.78 0.73 0.82 95 0.78 0.69 0.85
Mother treated for PPD?
yes 49 0.16 0.12 0.18 44 0.36 0.27 0.43
no 267 0.84 0.80 0.88 78 0.64 0.55 0.72
Help for mental health problems?
yes 16 0.05 0.03 0.06 21 0.17 0.11 0.22
no 300 0.95 0.92 0.97 101 0.83 0.75 0.89

difference between the two groups (v2 = 2.69, p = 0.26) nor
differences in educational levels (v2 = 6.85, p = 0.14) or age of
youngest child (v2 = 3.34, p = 0.65). Importantly, 32.2% of
fathers with children 13–18 months old reported depressive
symptoms above cut-off, compared to 25.9% and 26.8% among
fathers with infants 0–6 and 7–12 months, respectively. Among
fathers who had been or were on parental leave at the time of the
survey, 28.8% (76 out of 263) returned BDI-II scores indicating
at least mild depression, compared to 24.8% (43 of 173) among
fathers who had not been on parental leave, revealing no
difference (v2 = 4.34, p = 0.11). However, fathers with more than
one child were more frequent among those who scored above cut-
off (v2 = 10.1, p < 0.005). Fathers with a partner receiving help
for depression were also more frequent among those with BDI-II
scores above cut-off (36.1% and 15.6%, respectively; v2 = 20.8,
p < 0.0001). Stated differently, if the mother was receiving help,
the probability of the father scoring above the BDI-II cut-off was
0.47, compared to 0.23 if the mother was not receiving help for
PPD. Notably, the more severe the depression in the father, the
higher the probability that the mother was also receiving help
(0.27, 0.39 and 0.60 for mild, moderate and severe BDI-II
depression, respectively, v2 = 29.38, p < 0.0001, Table 2).
Finally, the majority of fathers with scores above the BDI-II mild
depression cut-off (82.8%, 100 out of 122) had not sought or
received professional help. Even most fathers among those with
BDI-II scores indicating moderate depression were without
professional contacts (84.8%, 39 of 46 fathers with scores 20–29).
Of the 15 fathers with BDI-II scores suggesting severe depression
(≥ 29), six had no professional contacts whatsoever (Table 2). In
response to BDI-II item 9, addressing suicidality, two fathers
reported will or intention to commit suicide. In response to EPDS
item 10, addressing self-harm, 42 fathers reported thoughts of
harming themselves, 27 of those had no professional contacts.
Item mean scores from all scales are listed in Table 3, for fathers
with scores below (n = 316) and above (n = 122) the BDI-II cut-
off of 14, respectively. The two groups responded significantly
different on all items.
Convergence of the depression scales
Cross tabulation of fathers below and above cut-off on each of the
three depression scales revealed convergence: 81.5% between the
BDI-II and the EPDS, 84.2% between the BDI-II and the GMDS-
distress subscale, and 78% between the GMDS and EPDS
(Table 4). Notably, of those fathers with scores above cut-off on
the BDI-II, 22 (18.3%) scored below cut-off on the EPDS.
Among fathers predominantly expressing depressive equivalent
symptoms, 18 (20%) scored lower than BDI-II cut-off, and 16
(17%) lower than the EPDS cut-off (Table 4). There were also
fathers who only reported traditional depressive symptoms above

© 2017 Scandinavian Psychological Associations and John Wiley & Sons Ltd
6 E. Psouni et al. Scand J Psychol (2017)

Table 3. Mean scores and group differences for EPDS, GMDS and BDI– Table 4. Convergence between BDI-II and EPDS; BDI-II and GMDS and
II items for fathers who scored below (n = 122) and above (n = 316) the EPDS and GMDS
BDI–II cut–off for mild depression
4a: Convergence between BDI-II and EPDS
BDI–II <14 BDI–II ≥14
Item M (SD) M (SD) t EPDS

EPDS 1 (no bright side) 0.3 (0.5) 1.2 (0.8) –10.93*** below cut-off above cut-off
EPDS 2 (not look fwd) 0.2 (0.4) 1.0 (0.8) –9.54***
EPDS 3 (guilt) 1.2 (0.8) 1.8 (0.8) –8.12*** n % n %
EPDS 4 (worry/fear) 0.9 (0.8) 1.6 (0.8) –8.20***
EPDS 5 (fear/panic) 0.3 (0.6) 1.0 (0.9) –7.28*** BDI-II below cut-off 258 58.9 58 13.2
EPDS 6 (too much) 1.2 (0.7) 1.9 (0.6) –11.07*** BDI-II above cut-off 23 5.3 99 22.6
EPDS 7 (unhappy/sleep pr) 0.3 (0.6) 1.3 (0.9) –12.36***
EPDS 8 (sad/miserable) 0.7 (0.7) 1.8 (0.7) –15.12*** 4b: Convergence between BDI-II and GMDS
EPDS 9 (unhappy/crying) 0.2 (0.4) 0.7 (0.7) –7.54***
EPDS 10 (self–harm) 0.0 (0.2) 0.4 (0.7) –5.44*** GMDS
GMDS 1 (low stress tole) 0.7 (0.7) 1.5 (0.9) –10.18***
GMDS 2 (aggressive/imp) 0.4 (0.6) 1.2 (0.9) –10.15*** below cut-off above cut-off
GMDS 3 (irritable/restless) 0.8 (0.7) 1.7 (0.8) –12.52***
GMDS 4 (worry) 0.2 (0.5) 0.9 (0.9) –8.34*** n % n %
GMDS 5 (new behaviors) 0.1 (0.3) 0.7 (0.8) –8.66***
GMDS 6 (self–pity) 0.2 (0.5) 1.0 (0.8) –9.61*** BDI-II below cut-off 297 67.9 19 4.3
GMDS 7 (alcohol etc) 0.2 (0.4) 0.7 (0.9) –6.55*** BDI-II above cut-off 50 11.4 72 16.4
BDI 1 (sadness) 0.1 (0.3) 0.9 (0.6) –13.11*** 4c: Convergence between EPDS and GMDS
BDI 2 (pessimism) 0.1 (0.3) 0.9 (0.8) –10.57***
BDI 3 (past failure) 0.2 (0.4) 1.0 (0.9) –10.66*** GMDS
BDI 4 (loss of pleasure) 0.1 (0.3) 1.0 (0.7) –12.61***
BDI 5 (guilty feelings) 0.3 (0.5) 1.2 (0.8) –10.74*** below cut-off above cut-off
BDI 6 (punishment feeling) 0.1 (0.3) 0.6 (0.9) –6.51***
BDI 7 (self–dislike) 0.0 (0.2) 1.1 (0.9) –12.74*** n % n %
BDI 8 (self–criticism) 0.2 (0.4) 1.0 (0.8) –11.03***
BDI 9 (suicidal thoughts) 0.0 (0.1) 0.3 (0.5) –5.67*** EPDS below cut-off 266 60.7 15 3.4
BDI 10 (crying) 0.1 (0.3) 0.6 (0.9) –6.34*** EPDS above cut-off 81 18.5 76 17.4
BDI 11 (agitation) 0.2 (0.5) 0.8 (0.7) –8.44***
BDI 12 (loss of interest) 0.4 (0.5) 1.2 (0.8) –10.31*** Notes: (a) Pearson v2 = 150.92, p < 0.0001, Cramer’s V = 0.59.
BDI 13 (indecisiveness) 0.2 (0.4) 1.0 (0.8) –10.30*** (b) Pearson v2 = 150.23, p < 0.0001, Cramer’s V = 0.58. (c) Pearson
BDI 14 (worthlessness) 0.1 (0.2) 0.9 (0.8) –10.55*** v2 = 113.51, p < .0001, Cramer’s V = 0.51
BDI 15 (loss of energy) 0.6 (0.6) 1.6 (0.7) –14.31***
BDI 16 (changes in sleep) 1.0 (0.6) 1.6 (0.8) –7.41***
BDI 17 (irritability) 0.5 (0.6) 1.3 (0.7) –12.14*** respectively (Fig. 1). As the ratio of first-to-second factor
BDI 18 (appetite changes) 0.3 (0.5) 1.0 (0.9) –9.27*** eigenvalue was above 5:1, a forced two-factor FA was carried out
BDI 19 (bad concentration) 0.3 (0.5) 1.2 (0.7) –12.02*** in a second round. The resulting division of items made
BDI 20 (tiredness/fatigue) 0.6 (0.6) 1.6 (0.7) –12.54*** theoretical sense as the first factor (9 items) captured mainly
BDI 21 (lost sex interest) 0.4 (0.6) 0.9 (1.0) –5.25***
depressive equivalent items while the second (8 items) gathered
internalizing symptoms of sadness/unhappiness, worry/anxiety
and thoughts of self-harm (Table 5).
cut-off: 50 (11.4%) according to the BDI-II, 79 (18%) according A combination of two most common techniques for item
to the EPDS. Thus, fathers with depressive symptoms above reduction (Coste, Guillemin, Pouchot & Fermanian, 1997; Goetz,
established cut-offs comprise a subgroup reporting traditional Coste, Lemetayer et al., 2013) was subsequently employed: Items
depressive symptoms only, a subgroup reporting depressive with factor loadings < 0.5 or a correlation with the composite
equivalents only, and a subgroup reporting both types of score of the 17-item pool < 0.5 were removed. Internal coherence
symptoms. for the twelve remaining items was high (Cronbach’s alpha =
0.90), while the correlation between the 12-item scale score and
the 17-item composite score was highly significant (r = 0.98, p <
A combined scale for assessing depressive symptoms in fathers 0.0001). Confirmatory factor analysis (maximum likelihood) on
EPDS and GMDS-distress items were pooled – the 17 items the second half of the database (n = 218) revealed adequate fit for
together were internally consistent (Cronbach’s alpha = 0.91). the full measurement model based on 12 observed indicators (the
Exploratory factor analysis (maximum likelihood) on the first half 12 selected items) and a single latent variable (v2(43) = 77.14, p <
of the database (n = 220) was performed. Preliminary analyses 0.001, CFI = 0.97, TLI = 0.95, RMSEA = 0.06). All indicators
suggested sampling adequacy (KMO = 0.92, Bartlett’s sphericity loaded significantly on to the latent variable (p < 0.01).
p < 0.0001), with a sufficient, 11:1 subject to item ratio. Since In a final round of analysis, the selected 12-items, to be called
factor relatedness could not be theoretically excluded, an oblimin Edinburgh-Gotland Depression Scale 12 (EGDS), were
rotation was employed. The analysis extracted three factors scrutinized for sensitivity and specificity using the BDI-II (cut-off
capturing 44.2%, 8.0% and 6.9% of the total variance, ≥ 14) as reference measure. ROC-curves were constructed for the

© 2017 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol (2017) Measuring postnatal depressive symptoms in fathers 7

Scree plot 1.0

ROC Curve
8

EGDS12
0.8
6 EPDS
Eigenvalue

0.6

Sensitivity
4

0.4

0.2

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 0.0
Factor number 0.0 0.2 0.4 0.6 0.8 1.0
1 - Specificity
Fig. 1. Scree plot to illustrate the eigenvalues from the exploratory factor
analysis on the first half of the database (n = 220). Fig. 2. ROC curve for the 12–item EGDS as well as the EPDS, measured
with the BDI-II (cut-off ≥ 14, indicative of mild major depression) as state
variable.
Table 5. EPDS and GMDS items: factor loadings and correlation with
entire item pool
the EPDS) at same levels of specificity (96% for the EPDS, 95%
Factor 1 Factor 2 r with r with for the EGDS). Applying instead a cut-off of ≥ 12 on the
entire composite score from all 17 (EPDS and GMDS-distress) items
a = 0.87 a = 0.83 pool BDI-II would result in comparable overall discriminating ability (AUC =
0.945) and high sensitivity (93%) but a much lower specificity
*GMDS 3 (irritable, restless, 0.80 0.72 0.61
frustrated) (77%). The 12 items included in the EGDS appear in the
*GMDS 2 (aggressiveness, 0.79 –0.10 0.69 0.57 Appendix.
impulsivity)
*EPDS 1 (no bright side 0.80 0.70 0.59
of things) DISCUSSION
*GMDS 1 (low stress tolerance) 0.65 0.70 0.53
*GMDS 5 (changed behavior) 0.63 0.13 0.70 0.65 The present study presents a first assessment of depressive
*EPDS 2 (not looking forward 0.66 0.62 0.58 symptoms in fathers up to 18 months postnatally with both the
to things) EPDS and the male depression GMDS, using the well validated
*GMDS 6 (self–pity) 0.55 0.15 0.67 0.60 self-report BDI-II as reference measure. This is an important first
*EPDS 6 (too much of things) 0.50 0.16 0.63 0.50
step towards identifying a set of items suitable for the reliable
GMDS 7 (alcohol, pills, 0.44 0.48 0.40
overwork etc) assessment of depressive symptoms in fathers in the postnatal
*EPDS 7 (unhappy/sleep 0.39 0.50 0.76 0.69 period. Our hypothesis that many fathers are acting out their
problems) depression, thereby experiencing and reporting “depressive
EPDS 9 (unhappy, been crying) 0.23 0.62 0.45 0.51 equivalents” (Rice et al., 2013; Rutz, 1996), received support as,
*EPDS 5 (fear, panic) 0.60 0.61 0.46
indeed, a subgroup reported exclusively such depressive
*EPDS 10 (self–harm thoughts) 0.21 0.53 0.50 0.58
*EPDS 8 (sad/miserable) 0.34 0.53 0.79 0.70 equivalents, similar to previous findings (Madsen & Juhl, 2007).
GMDS 4 (worry, discomfort) 0.38 0.30 0.64 0.56 If men who experience depressive equivalent symptoms are also
EPDS 3 (guilt) 0.50 0.49 0.41 less inclined to openly reflect over their feelings, and thus choose
EPDS 4 (worried, afraid) –0.11 0.68 0.49 0.39 to not participate in a survey, the subgroup of fathers
experiencing exclusively depressive equivalents in the general
Note: *Indicates items included in the final scale based on the inclusion
criteria. population may be larger than in our sample.
The items measuring depressive equivalents and those
measuring traditional depressive symptoms correlated highly with
12-item EGDS and the EPDS (Fig. 2) and the area under the each other. This finding highlights the coexistence of traditional
curve (AUC) was used to evaluate the overall discriminating depressive symptoms and depressive equivalents in men, and
ability of the scales (Hajian-Tilaki, 2013). Cut-offs ≥ 9, ≥ 10, ≥11 further supports the hypothesis that both groups of symptoms are
and ≥ 12 were explored (Table 6). With the BDI-II (cut-off ≥ 14) implicated in depression in fathers postnatally. Furthermore, it
as reference, the EGDS with cut-offs ≥ 8 and ≥ 9 showed higher appears that an instrument that combines traditional and
sensitivity than the EPDS in the present sample, with similar depressive equivalent symptoms is more adequate for the
specificity. A cut-off of ≥ 11 showed comparable specificity as assessment of depression in fathers. Indeed, compared to BDI-II,
the EPDS (91.4% compared to 93.4%) at higher sensitivity the EGDS demonstrated improvement in sensitivity at equal
(75.0% compared to 65.5% for the EPDS) while a cut-off of ≥ 12 levels of specificity compared to the sensitivity demonstrated for
resulted also in higher sensitivity (69% compared to 55.5% for the recommended cut-off of ≥ 9 in the EPDS validation study

© 2017 Scandinavian Psychological Associations and John Wiley & Sons Ltd
8 E. Psouni et al.
Table 6. Internal consistency, sensitivity and specificity of the EPDS and EGDS, evaluated against BDI-II (cut-off ≥ 14).
EPDS
Cronbach’s alpha 0.85
AUC 0.929
Cut-off value ≥9 ≥ 10 ≥ 11
Sensitivity 81.9% 75.9% 65.5%
Specificity 81.5% 89.4% 93.4%
with men in the postnatal period (EGDS 90.5%, compared to
EPDS 71.4% in Matthey et al., 2001). With a cut-off of ≥ 11,
similar to the stricter EPDS cut-off suggested by Matthey et al.
(2001), the EGDS returned specificity comparable to that of the
EPDS but secured higher sensitivity. The most stringent cut-off of
≥ 12, equal to what has been suggested as indicative of major
depression with the EPDS (Massoudi et al., 2013), also returned
higher sensitivity at similar levels of specificity. Notably, using
the entire EPDS and GMDS-distress scales (17 items) with the
same cut-off would have secured even higher sensitivity but at
lower levels of specificity. Our results suggest, therefore, that
most appropriate as screening for depressive symptoms among
fathers postnatally is a sub-set combining selected items from
these scales. Given the low help-seeking behavior of men,
improved sensitivity in screening instruments can be particularly
important for detecting fathers with depressive symptoms.
Because it addresses both traditional and male depressive
symptoms, apparently common among many fathers, the EGDS
may also have higher construct validity in use with fathers,
compared to the EPDS. Future research ought to explore this
possibility.
Since we chose to adapt the timeframe of all instruments used
in the survey to two weeks, the EGDS uses a two-week
timeframe when asking for frequency of symptoms, consistent
with the timeframe in the BDI-II and several major diagnostic
clinical interviews. The high internal consistency of the EPDS
and GMDS, respectively, in the present study, and the high
concordance among the different depression measures, are
consistent with psychometric properties for the EPDS and GMDS
reported for the one-week and four-week timeframes, respectively,
suggesting that there is no disadvantage from using items from
these measures with a two-week timeframe. This timeframe is
also consistent with the DSM-5 requirement that symptoms in
major depressive disorder must have persisted for a time period of
at least two weeks, possibly rendering increased face-validity for
the EGDS.
Overall, 28% of fathers in the present study reported depressive
symptoms above the BDI-II cut-off for mild depression, almost
14% above the BDI-II cut-off for moderate depression. These
frequencies of burdening depressive symptoms are high
compared, for example, to the 10.3% prevalence reported in
Bergstr€om (2013) based on an EPDS cut-off of ≥ 11. Notably, an
EPDS cut-off of ≥ 11 in the present study would still have
resulted in a frequency of 23% of fathers with symptoms above
cut-off. A self-selection bias partly explains this high prevalence:
it cannot be ruled out that fathers who experienced a
compromised psychological well-being may have felt particularly
motivated to share their experiences through the survey. The
© 2017 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol (2017)
EGDS (12–item)
0.90
0.937
≥ 12 ≥9 ≥ 10 ≥ 11 ≥ 12
55.5% 90.5% 82.8% 75.0% 69.0%
96.0% 80.5% 87.1% 91.4% 95.0%
relatively high percentage of partners of participants suffering
depressive problems (here, 21% receiving/scheduled to receive
help for depressive symptoms, compared to prevalence of PPD
among mothers of 13%: O’Hara & McCabe, 2013) is also
consistent with a potential self-selection bias. While suffering
fathers were not actively sought after, information about the study
mentioned, for ethical reasons, a general aim of understanding
fathers’ thoughts and feelings. In a depression study with a
similar online recruitment procedure, a third of the participants
had earlier been diagnosed with depression (Rice, 2011). A third
consideration concerns the presence of items in the BDI-II, e.g. “I
am too tired or fatigued to do most of the things I used to do”
(BDI II item 20), that open the measure up to contamination with
typical behaviors in the postnatal period. Notwithstanding these
reservations, the high prevalence of fathers reporting depressive
symptoms above referral cut-offs indicates that paternal postnatal
depression is an existing and common phenomenon, contrary to
notions from previous decades (Lane, Keville, Morris, Kinsella,
Turner & Barry, 1997). The risks of compromised parenting
quality, worsened partner relationships and effects on children
empirically associated with this phenomenon (Letourneau et al.,
2011; Ramchandani et al., 2005, 2008) motivate a
(re)consideration of the policies for addressing it.
The factor most strongly associated with self-reported
depressive symptoms in fathers was presence of mental health
problems in the mother, consistent with other findings (Goodman,
2004), highlighting the need of routinely assessing the mental
health of fathers whose partners suffer from PPD. In such cases, it
may be necessary to support fathers in coping with their partner’s
PPD (Letourneau et al., 2012). Lower educational level, recent
experiences of stressful life events such as divorce or trauma/
illness, and having more than one child were also associated with
depression in fathers but differences between these groups in
terms of self-reported depressive symptoms were small,
suggesting that paternal depression occurs across all groups of
fathers and should be addressed widely. While it was beyond the
scope of the present study to assess the contribution of screening
based on self-report, compared to other alternatives to this end,
our findings highlight that if self-report screening for burdening
depressive symptoms should be used for fathers, it ought to be
based on a measure that combines EPDS with depressive
equivalent items, such as the proposed EGDS.
Remarkably, 83% of fathers who scored above the BDI-II cut-
off for suspected depression had not made their suffering known
to any professional (92% and 74% for fathers who scored above
the mild and moderate depression cut-offs, respectively). The
respective number for mothers is roughly estimated at about 50%
(Ramsay, 1993). Even among fathers whose BDI-II score
Scand J Psychol (2017)
suggested severe depression, 40% had no professional contacts
for support or treatment. This is notable considering that fathers
who participated in the study invested at least 30 minutes to
respond to the questions, suggesting that they were perhaps not
negative to reflecting upon their wellbeing and admitting to
symptoms of depression. Among depressed fathers unwilling to
reflect upon, and potentially admit to, such symptoms, the
numbers of depressed fathers not seeking and thereby not
receiving help may be larger. The high number of fathers with
depressive symptoms suggesting at least mild depression in our
findings, and previous evidence of low help-seeking behavior in
men (Diaz-Granados et al., 2010; Mahalik et al., 2007), suggest
that screening for depression among new fathers could be a
means of identifying fathers potentially in need of professional
support. A screening routine might also promote in fathers a sense
of being “seen” by healthcare professionals, the lack of which has
been discussed as a major theme contributing to depressed
fathers’ feelings of powerlessness (Edhborg, Carlberg, Simon &
Lindberg, 2015). Given the scarcity of fathers who consider the
option of communicating to a perinatal healthcare professional
potential mental health difficulties (Massoudi, 2013), a screening
routine based on a self-report measure such as the EGDS may be
more effective in capturing signs of paternal postnatal depression
than, for example, a face-to-face interview with a perinatal
healthcare professional. On a more general level, men’s non-help-
seeking attitude related to depression ought to receive more
attention in the public discussion, combined with broad
psychoeducational techniques, such as brochures targeting non-
help-seeking attitudes in men, which has previously shown some
positive effects (Hammer & Vogel, 2010; Rochlen, McKelley &
Pituch, 2006).
Notably, the rate of fathers in the 13–18 month postnatal
period who reported depressive symptoms above the BDI-II
cut-off for mild depression (32.2%) was equal to those of
fathers in the 0–6 and 7–12 month postnatal periods (25.9%
and 26.8%, respectively). This finding is not surprising,
considering the meta-analytic evidence of flat rates of
prevalence across the entire first postnatal year (Cameron et al.,
2016) and the higher depression rates among fathers at the end,
compared to the beginning, of the first year (Escriba-Ag€ uir &
Artazcoz, 2011). The fact that very few fathers seek, and
therefore receive, help for their depressive symptoms, probably
also contributes to the sustained rates of fathers with BDI-II
scores indicating depression after the end of the first postnatal
year. Asking about father depression in the second postnatal
year has not been praxis in the field, so this first indication that
paternal depression may be equally frequent after the end of the
first postnatal year needs further empirical substantiation. In the
specific case of Sweden, where fathers are commonly on
parental leave with primary care for their child during the end
of the first and beginning of the second year of the child’s life,
information about fathers’ mental health in the beginning of
children’s second year of life is precious.
Limitations and suggestions for future research
The current study suffers some limitations. While the BDI-II is
widely used and well validated as self-report assessment of
© 2017 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Measuring postnatal depressive symptoms in fathers 9
depression (Brodey et al., 2016; Hobkirk et al., 2015; Wu &
Huang, 2010), and demonstrated high reliability and construct
validity in the present sample, it does reflect the individual’s own
report of depressive symptoms. Despite evidence that self-report
measures are quite accurate in assessing emotions and behaviors
(Spain, Eaton & Funder, 2000), a structured clinical interview
with fathers who scored above referral cut-offs on the BDI-II
would have made possible the confirmation of a diagnosis of
depression. As this step was not taken in the present study, the
proposed EGDS must in a next round of research be validated
against a clinical interview. It could furthermore be argued that
the BDI-II is not the optimal reference depression scale when
assessing men, since it in itself does not include depressive
equivalents. However, no gender neutral depression scale known
to the authors had been validated at the time of the investigation
(e.g. Gender Inclusive Depression Scale: Martin et al., 2013).
Future research could also investigate whether “unpacking” the
GMDS item7 that comprises five behaviors (abusing alcohol,
pills, food, sports, work) might result in additional items with
distinct diagnostic value.
The online survey used for data collection was suitable for
recruitment among groups of men who would most likely not be
accessed through the child healthcare system. However, the high
education levels among participants imply increased ability and
willingness to reflect upon mental states such as symptoms of
depression. Fathers exhibiting aggressive behaviors or substance
abuse are perhaps less likely to take part in surveys that require
such reflection. Also, because of the cognitive demands required
for responding to surveys, testing online may have resulted in an
underrepresentation of fathers not used to reading longer texts or
with difficulties to concentrate (such as fathers with ADHD).
Finally, it cannot be excluded that some participants may have
shared inaccurate information about the age of their infants. In a
new round of research, replication and validation would require
recruiting fathers based on birth records.
Furthermore, the EPDS has been criticized for its low
sensitivity in detecting PPD in mothers. A Swedish report (SBU,
2014) found around 70% detection rates among depressed
mothers postpartum. As depressive equivalent symptoms have
been reported also by women in a few studies (M€ oller-
Leimk€ uhler & Y€ ucel, 2010; Rice et al., 2013), the concept of
depression might require revisiting for both men and women.
Changes in social roles and gender expectations affect the
expression of depression, while transition to parenthood often
involves experiences of stress which might trigger atypical
depressive symptoms, such as aggressiveness, in both women and
men. Therefore, the extent to which scales such as the proposed
EGDS may be particularly useful for capturing suspected
depression not only in new fathers but also mothers, remains to
be explored. It would also be of interest to study its ability to
measure depression in the prenatal period.
Future research about paternal PPD should also consider
minority groups. The present study was administered in Swedish
thus excluding non-Swedish speaking fathers. Further knowledge
is essential about which expressions of depression which are
common, or acceptable, among fathers belonging to cultural/
ethnic minorities in Sweden. Finally, research about PPD has
been based on the assumption that there are two categories of
10 E. Psouni et al.
parents, mothers and fathers. Future research ought to construe
parental well-being beyond the categories of mothers identifying
themselves as women, or fathers identifying themselves as men.
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Edition (BDI–II) across gender, race, and ethnicity in college students. I/others have noticed that I have a lower stress threshold – I am
Assessment, 20, 419–428 more stressed out than usual.
World Health Organization (2008). Maternal Mental Health and Child
Health and Development: Literature review of risk factors and 0 Not at all
interventions on Postpartum Depression. WHO, Department of Mental 1 To some extent
Health and Substance Abuse. 2 Very true
Wickberg, B. & Hwang, C. (1996). The Edinburgh Postnatal Depression 3 Extremely so
Scale: Validation on a Swedish community sample. Acta Psychiatrica I feel that my behavior has altered in such a way that neither I
Scandinavica, 94, 181–184.
Wilson, S. & Durbin, C. E. (2010). Effects of paternal depression on
myself nor others can recognize me, and that I am difficult to deal
fathers’ parenting behaviors: A meta-analytic review. Clinical with.
Psychology Review, 30, 167–180. 0 Not at all
Wu, P.-C. & Huang, T.-W. (2010). Person heterogeneity of the BDI-II-C 1 To some extent
and its effects on dimensionality and construct validity: Using mixture 2 Very true
item response models. Measurement and Evaluation in Counseling 3 Extremely so
and Development, 43, 155–167.
Walinder, J. & Rutz, W. (2001). Male depression and suicide. I have looked forward with enjoyment to things.
International Clinical Psychopharmacology, 16, S21–S24. 0 As much as I ever did
Zierau, F., Bille, A., Rutz, W. & Bech, P. (2002). The Gotland Male 1 Rather less than I used to
Depression Scale: A validity study in patients with alcohol use 2 Definitely less than I used to
disorder. Nordic Journal of Psychiatry, 56, 265–271. 3 Hardly at all

Received 12 January 2017, accepted 5 September 2017 I/others have noticed that I am more aggressive, outward
reacting, difficulties keeping self–control.
0 Not at all
APPENDIX: EPDS AND GMDS ITEMS INCLUDED IN THE
1 To some extent
12 ITEM EGDS 2 Very true
Please mark the answer which comes closest to how you have felt 3 Extremely so
during the past two weeks, including today. During the past two
The thought of harming myself has occurred to me.
weeks:
3 Yes, quite often
I have been able to laugh and see the funny side of things. 2 Sometimes
1 Hardly ever
0 As much as I always could
0 Never
1 Not quite so much now
2 Definitely not so much now I/others have noticed that I am more irritable, restless and
3 Not at all
frustrated.
I have felt scared or panicky for no very good reason. 0 Not at all
3 Yes, quite a lot 1 To some extent
2 Yes, sometimes 2 Very true
1 No, not much 3 Extremely so
0 No, not at all
Things have been getting on top of me.
I have been so unhappy that I have had difficulty sleeping. 3 Yes, most of the time I haven’t been able to cope
3 Yes, most of the time 2 Yes, sometimes I haven’t been coping as usual
2 Yes, sometimes 1 No, most of the time I have coped right well
1 Not very often 0 No, I have been coping as well as ever
0 No, not at all
I have noticed that I have a greater tendency for self–pity, to be
I have felt sad or miserable. complaining or to seem “pathetic”.
3 Yes, most of the time 0 Not at all
2 Yes, quite often 1 To some extent
1 Not very often 2 Very true
0 No, not at all 3 Extremely so

© 2017 Scandinavian Psychological Associations and John Wiley & Sons Ltd