Issues in Mental Health Nursing

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Postpartum Depression is a Family Affair:

Addressing the Impact on Mothers, Fathers, and
Children

Nicole Lyn Letourneau, Cindy-Lee Dennis, Karen Benzies, Linda Duffett-

Leger, Miriam Stewart, Panagiota D. Tryphonopoulos, Dave Este & William
Watson

To cite this article: Nicole Lyn Letourneau, Cindy-Lee Dennis, Karen Benzies, Linda Duffett-Leger,
Miriam Stewart, Panagiota D. Tryphonopoulos, Dave Este & William Watson (2012) Postpartum
Depression is a Family Affair: Addressing the Impact on Mothers, Fathers, and Children, Issues in
Mental Health Nursing, 33:7, 445-457, DOI: 10.3109/01612840.2012.673054

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Issues in Mental Health Nursing, 33:445–457, 2012
Copyright © 2012 Informa Healthcare USA, Inc.
ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.3109/01612840.2012.673054

Postpartum Depression is a Family Affair: Addressing

the Impact on Mothers, Fathers, and Children

Nicole Lyn Letourneau, PhD, RN

University of Calgary, Faculty of Nursing, Alberta, Canada, and University of New Brunswick,
Faculty of Nursing, Fredericton, New Brunswick, Canada

Cindy-Lee Dennis, PhD, RN

University of Toronto, Lawrence S. Bloomberg Faculty of Nursing, Toronto, Canada

Karen Benzies, PhD, RN

University of Calgary, Faculty of Nursing, Calgary, Canada

Linda Duffett-Leger, PhD, RN

University of New Brunswick, Faculty of Nursing, Fredericton, Canada

Miriam Stewart, PhD, FRSC, FCAHS

University of Alberta, Faculty of Nursing, Edmonton, Alberta, Canada

Panagiota D. Tryphonopoulos, PhD, RN

University of New Brunswick, Faculty of Nursing, Fredericton, Canada

Dave Este, MSW, PhD

University of Calgary, Faculty of Social Work, Calgary, Canada

William Watson, MSc, MD, FCFP

University of Toronto, Dalla Lana School of Public Health, Toronto, Canada

Wilson, & Romaniuk, 2003; L. Murray, Sinclair, Cooper,

The purpose of this paper is to present research on the ef-
fects of postpartum depression (PPD) on mothers, fathers, and
children that point to a re-conceptualization of PPD as a mental
health condition that affects the whole family. As such, the objec-
tives of this paper are to discuss: (1) the incidence and effects of
PPD on mothers and fathers; (2) common predictors of PPD in
mothers and fathers, and (3) the effects of PPD on parenting and
parent-child relationships, and (4) the effects of PPD on children’s
health, and their cognitive and social-emotional development. Fi-
nally, the implications for screening and intervention if depression
is re-conceptualized as a condition of the family are discussed.
Postpartum depression (PPD) negatively affects women’s
functioning, marital and personal relationships, maternal-infant
interaction quality, and children’s social and cognitive develop-
mental outcomes (Cooper & Murray, 1997; L. Murray, Cooper,
Address correspondence to Nicole Letourneau, Faculty of Nursing,
University of Calgary, Office 2282/2293, 2500 University Dr. NW,
Alberta, Canada, T2N 1N4. E-mail: nicole.letourneau@ucalgary.ca
Ducournau, & Turner, 1999). Fathers also are affected by PPD,
either directly by experiencing depression themselves during the
postpartum period, or indirectly in supporting and coping with
their partner’s symptoms (Paulson & Bazemore, 2010). While
calls to provide family-centred interventions for PPD have been
made since at least the late 1990s (Boath, Pryce, & Cox, 1998),
interventions for PPD typically focus on alleviating mothers’
symptoms and often minimize the impacts of PPD on partners
and children. The purpose of this paper is to conduct a real-
ist review (Pawson, Greenhalgh, Harvey, & Walshe, 2005) that
highlights PPD as a mental health condition affecting the whole
family through consideration of: (1) the incidence and effects of
PPD on mothers and fathers; (2) predictors of PPD in mothers
and fathers; (3) the effects of PPD on parenting and parent-
child relationships; (4) the effects of PPD on children’s health,
cognitive, and social-emotional development; and (5) the policy
and program implications for psychiatric mental health nursing
screening and intervention. The aim of this review is to provide
a deeper understanding of PPD and related interventions.

445
446 N. L. LETOURNEAU ET AL.
IMPACT OF PPD ON MOTHERS AND FATHERS
Postpartum mood disorders represent the most frequent form
of maternal morbidity following delivery (Stocky & Lynch,
2000). The risk of major depression that requires admission
to hospital is greater in the postpartum period than at any other
time in a woman’s life (Boath et al., 1998). A meta-analysis of
28 studies reported an overall prevalence of PPD of 15% (Gavin
et al., 2005). PPD, or major depression with postpartum onset, is
characterized by the symptoms of depressed mood and loss of in-
terest or pleasure and at least three of the following: psychomo-
tor agitation or retardation, insomnia or hypersomnia, reduced
concentration and decisiveness, fatigue or loss of energy, weight
loss or weight gain, and suicidal ideation (American Psychiatric
Association [APA], 2000); symptoms must be experienced by
mothers consistently during a two-week period and represent
a change from previous functioning. Although the Diagnostic
and Statistical Manual indicates that mothers must experience
symptoms within four weeks postpartum (APA, 2000), most of
the literature includes the first postpartum year when defining
PPD (Gavin et al., 2005). The inception rate is greatest in the first
12 weeks postpartum (Cooper & Murray, 1998) with duration
frequently dependent on severity of symptoms (Cox, Murray,
& Chapman, 1993) and time to onset of treatment (England,
Ballard, & George, 1994). Residual depressive symptoms are
common (Cooper & Murray, 1997), with 50% of mothers with
PPD remaining clinically depressed at six months postpartum
(Boath et al., 1998), and 25% of mothers with untreated PPD
remaining clinically depressed past the first year (Carpiniello,
Pariante, Serri, Costa, & Carta, 1997). A population-based study
of the first year postpartum revealed that the rate of maternal ad-
mission or outpatient contact for mental illness is 1.03 per 1000
births (Munk-Olsen, Laursen, Pedersen, Mors, & Mortensen,
2006a). Furthermore, mothers affected by PPD are estimated
to be 300 times more likely to experience a recurrence during
subsequent pregnancies, and are twice as likely to have a major
depression relapse within five years of giving birth, than moth-
ers who never experienced PPD (Hamilton & Sichel, 1992).
Recent research suggests that 63% of women who experience
symptoms of depression postpartum are prone to relapse over
the next 11 to 12 years (Letourneau, Salamani, & Duffett-Leger,
2010).
PPD places mothers at increased risk of social isolation due
to lack of energy, fatigue, and feelings of incompetence, worth-
lessness, and helplessness. Mothers are most likely to rely on
their partners for support (Holopainen, 2002), placing addi-
tional strain on these intimate relationships. PPD has been as-
sociated with marital problems such as disagreements, hostility,
withdrawal of social support between marital partners (Davies
& Windle, 1997; Leinonen, Solantaus, & Punamaeki, 2003),
as well as separation and divorce (Meadows, McLanahan, &
Brooks-Gunn, 2007). Maternal mental health problems and re-
duced social support, including decreased intimacy between
partners, may function to further compromise maternal mental
health. Nearly 50% of mothers with PPD experience intrusive
thoughts about suicide and infanticide (Barr & Beck, 2008;
Fairbrother & Woody, 2008), and their fear of disclosing these
disturbing thoughts often prevents them from seeking the sup-
port they need to recover (Barr & Beck, 2008) (Letourneau et al.,
2007).
When mothers experience PPD, 24% to 50% of partners
will also experience depression (J. Goodman, 2004b). A recent
meta-analysis (43 studies with 28,004 participants) suggests
that approximately 10% of fathers will experience depression
in the first year postpartum (Paulson & Bazemore, 2010), a rate
significantly higher than the 12-month prevalence of 5% for
major depression in men (Kessler, Berglund, & Demler, 2003).
Unlike mothers, in whom the onset of PPD is usually in the
early PPD period, depression in men begins later and more
gradually, often following the onset in women, with the rate
in fathers increasing over the first year (Kim & Swain, 2007;
Matthey, Barnett, Ungerer, & Waters, 2000). Two studies have
found that approximately 50–60% of fathers with depression
at 6–8 weeks postpartum remain symptomatically depressed
at six months, suggesting consistency in symptom duration
(Ballard, Davis, Cullen, & Mohan, 1994; Zelkowitz & Milet,
2001). A population-based study of the first year postpartum re-
vealed that the rate of admission or outpatient contact for mental
illness is 0.37 per 1000 births for fathers (Munk-Olsen, Laursen,
Pedersen, Mors, & Mortensen, 2006b).
Men are less likely than women to seek the help of health
professionals or access health services for mental health needs
(Addis & Mahalik, 2003; Mahalik, Englar-Carlson, & Good,
2003; O
Brien, Hunt, & Hart, 2005), a finding that is attributed
to men’s and societal attitudes about gendered approaches to
help-seeking and suggests men should be reluctant to seek help
(Letourneau, Dennis, Stewart, Duffett-Leger, & Tryphonopou-
los, 2011). Since males are less likely to seek support, they may
be more prone to caregiver burden, characterized by the strain
endured by individuals responsible for the constant care and
attention of another (Kasuya, Polgar-Bailey, & Takeuchi, 2000;
Tsang, Tam, Chan, & Chang, 2003). Burdened caregivers often
report anxiety, fatigue, distress, worry, frustration, powerless-
ness, guilt, and despair, and may experience depressive symp-
toms such as sleep disturbances and diminished appetite and
energy (Baronet, 1999; Kasuya et al., 2000; Rose, Mallinson, &
Gerson, 2006).
Fathers suffering from depression alongside their partners
with PPD have reported marital difficulties associated with
poor communication, less optimal interactions with their chil-
dren, and feelings of being overwhelmed, isolated, stigmatized,
and frustrated (Davey, Dziurawiec, & O
Brien-Malone, 2006).
Asymptomatic fathers (n = 8) whose partners suffered from
PPD reported: (1) significant changes in their partner’s behav-
ior, (2) fear, confusion, and concern for their spouse, and (3)
feelings of frustration and helplessness associated with their
inability to help in their partner’s recovery from PPD. All of
the men, both depressed and non-depressed, reported stress and
fatigue from increasing demands, while many also described
 POSTPARTUM DEPRESSION AND ITS IMPACT ON THE FAMILY
feelings of anger and resentment (Davey et al., 2006). Thus, the
new father’s stress is magnified by his attempts to cope with
the demands of his partner’s mental health, a new infant and
possibly other children, as well as employment commitments
(Meighan, Davis, Thomas, & Droppleman, 1999). Further com-
plicating matters, paternal aggression and intimate partner vi-
olence (Hedin, 2000; Roberts, Bushnell, Collings, & Purdie,
2006), substance abuse (Tannenbaum & Forehand, 1994), and
economic stress (Boath et al., 1998; Ram & Hou, 2003) may
also be associated with paternal depression.
PREDICTORS OF PPD POINT TO FAMILY CONNECTION
Most research on the impact of PPD on the family unit has
focused on heterosexual couples with biological children; how-
ever, since increasing numbers of gay men and lesbians are
becoming parents (Gates, Badgett, Macomber, & Chambers,
2007), the exploration of sexual minorities as they transition into
parenthood is needed. To date, only one study has examined the
mental health outcomes of lesbians and gay men across the first
year of parenthood and found that higher perceived workplace
support, family support, and relationship quality was associated
with lower depressive symptoms at the time of the adoption
(Goldberg & Smith, 2011). Moreover, limited research points
to possible biological explanations for PPD in both mothers and
fathers, but an extensive body of research demonstrates the in-
fluence of both psychosocial stressors and marital relationships
as risk factors for PPD.
Biological Explanations
Despite a large body of literature that has sought to explain
maternal PPD by fluctuating levels of hormones such as es-
trogen (Feng et al., 2001; D. Murray, 1996) and thyroid hor-
mones (Pederson, 1999), results remain equivocal. While recent
research suggests that neuroendocrine and inflammatory pro-
cesses (Corwin & Johnston, 2008; Corwin & Pajer, 2008) and
polymorphisms of genes regulating monoamines in the central
nervous system also have been implicated in the pathogenesis
of PPD, conclusions remain premature (Corwin, Kohen, Jarrett,
& Stafford, 2010). There is very little research on biological
predictors for paternal depression. While limited, evidence sug-
gests that low testosterone levels are linked to depression in
men (Seidman & Walsh, 1999) and men’s testosterone levels
typically decrease prior to and several months after the birth
of their child (Fleming, Corter, Stallings, & Steiner, 2002; Kim
& Swain, 2007; Storey, Walsh, Quinton, & Wynne-Edwards,
2000). This timing may be consistent with findings from a
meta-analysis, in which rates of prenatal and PPD in fathers
were relatively higher in the 3- to 6-month postpartum period
than in the first three months following birth (Paulson & Baze-
more, 2010). Cortisol levels and vasopressin changes associated
with environmental stress pose biological risks for both mater-
nal and paternal depression (Corwin & Pajer, 2008; Young,
1999).
447
Psychosocial Stressors
Factors contributing to the symptoms of PPD in women in-
clude lack of social support, low self-esteem, inability to cope,
feelings of incompetence, loss of self, and social isolation (Beck,
2001; Brugha et al., 1998; Logsdon & Usui, 2001; O’Hara &
Swain, 1996; Seguin, Potvin, St-Denis, & Loiselle, 1999; Web-
ster et al., 2000). A mother’s attachment representation of her
relationship with her child, rooted in her own caregiving his-
tory, predicts persistence of depressive symptoms (Trapolini,
Ungerer, & McMahon, 2008). For fathers, societal expectations
and growing responsibilities during the postpartum period (Kim
& Swain, 2007) and increased emphasis on the man’s role as fi-
nancial provider (Morse, Buist, & Durkin, 2001) create psycho-
logical distress contributing to the development of depression.
Further, men’s assessment of fatherhood as either beneficial or a
burden has been linked to their perceptions of stressors and sup-
port, both available and accessed (Garfield, Clark-Kauffman, &
Davis, 2006).
Marital Relationships
Paternal depression can reduce marital quality (Boath et al.,
1998), which subsequently predicts depressive relapse in moth-
ers (Coyne, Thompson, & Palmer, 2002). Paternal depres-
sion correlates with maternal depression (r = .31) (Paulson &
Bazemore, 2010) and is often the consequence of more severe
maternal symptoms of PPD (Pinheiro et al., 2006). Marital dis-
satisfaction is a strong risk factor for maternal (Beck, 2001;
O’Hara & Swain, 1996) and paternal PPD (J. Goodman, 2004b;
Paulson & Bazemore, 2010; Vivian & Malone, 1997). The sud-
den life changes associated with the transition to parenthood
often threaten marital relationships during the early postpar-
tum period (Anderson, 1996). Indeed, PPD has been associated
with decreased relationship satisfaction (Bielawska-Batorowicz
& Kossakowska-Petrycka, 2006; Buist, Morse, & Durkin, 2002;
Dudley, Roy, Kelk, & Bernard, 2001) and marital problems,
such as lack of intimacy and sexual issues (Meighan et al.,
1999), sometimes resulting in separation or divorce (Sayers,
Kohn, Fresco, Belleck, & Sarwer, 2001).
Maternal mental health problems are also related to family
functioning by potentially evoking disagreements and hostil-
ity between parents, which frequently result in a withdrawal
of social support between marital partners (Leinonen et al.,
2003). Depression is associated with impaired interpersonal
interactions between partners characterized by anger, hostil-
ity, mistrust, emotional detachment, reduced nurturance and
affiliation (Feldbau-Kohn, Heyman, & O
Leary, 1998; Kahn,
Coyne, & Margolin, 1985), and intimate partner violence (Vaeth,
Ramisetty-Mikler, & Caetano, 2010). These interactive charac-
teristics function to further complicate mothers’ symptoms of
depression (Cohen et al., 2002). Compared to non-depressed
men, depressed fathers make greater use of less positive and
angry expressions in interactions with their partners thereby in-
creasing depressive symptomatology and the odds of engaging
448 N. L. LETOURNEAU ET AL.
in moderate physical aggression (e.g., pushing) and severe ag-
gression (e.g., beating) (Pan, Neidig, & O
Leary, 1994).
INFLUENCES OF PPD ON PARENTING COGNITIONS
AND PARENT-INFANT RELATIONSHIPS
The negative consequences of maternal PPD on parent-
ing cognitions and parent-child relationships are well known
(Field, 2010). Evidence suggests that depressed mothers are
significantly: (1) more likely to engage in risky parenting
practices (e.g., corporal punishment, reduced home safety
practices, non-attendance at child well-health visits); (2) less
likely to have knowledge about infant development and age-
appropriate nurturing and sensitive parenting; and (3) less
likely to perform literacy enrichment activities (Zajicek-Farber,
2010).
Maternal Cognitions and Maternal-Infant Relationships
Maternal depression has been described as the “thief that
steals motherhood” (Beck, 1999) as it reduces mothers’ en-
joyment in the maternal role (p. 41). As described in sev-
eral systematic reviews, maternal depression has a moderate
to large effect on mothering of infants (Beck, 1995; Field, 2010;
Logsdon, Wisner, & Pinto-Foltz, 2006) and is associated with
parenting deficits (Lovejoy, Graczyk, O’Hare, & Neuman,
2000). Depressed mothers often display reduced sensitivity
and responsiveness in interactions with their infants (Hipwell,
Goossens, Melhuish, & Kumar, 2000; L. Murray, Fiori-Cowley,
Hooper, & Cooper, 1996), fail to provide positive feedback to
meet infants’ social-emotional needs (Beck, 1995; van Doesum,
Hosman, Riksen-Walraven, & Hoefnagels, 2007), and are more
inappropriate and negative in play (Righetti-Veltema, Bousquet
et al., 2003). They also speak more slowly and less often (Teas-
dale, Fogarty, & Williams, 1980), and are less affectionate and
more anxious in interactions (Righetti-Veltema et al., 2003;
Stanley, Murray, & Stein, 2004) than non-depressed mothers.
Associations between maternal depression and reductions in
healthy infant feeding and sleep practices also have been noted
(Field, 2010; Paulson, Dauber, & Leiferman, 2006). Depressed
mothers often question their parental competence (Gelfand &
Teti, 1990; S. Goodman, Brogan, Lynch, & Fielding, 1993)
and their ability to positively influence their children’s develop-
ment (Kochanska, Kuczynski, Radke-Yarrow, & Welsh, 1987).
Depressive symptoms interfere with the ability to apply appro-
priately firm and consistent discipline (Lovejoy et al., 2000;
Marchand & Hock, 1998), which may lead to excess criti-
cism, hostility, and rejection of children (Cummings, Keller,
& Davies, 2005; Kaslow, Deering, & Racusin, 1994; Lovejoy
et al., 2000; Marchand & Hock, 1998). More punitive parent-
ing may be the result of negative appraisals and lower toler-
ance for their children’s behaviors (Cornish, McMahon, & Un-
gerer, 2008; L. Murray & Cooper, 1996; Schaughency & Lahey,
1985).
Paternal Cognitions and Paternal-Infant Relationships
Less is known about the links among paternal depression,
parenting cognitions, and fathers’ relationships with their chil-
dren. Fathers play a significant role in promoting their children’s
development by protecting their partners from a depressive re-
lapse (Misri, Kostaras, Fox, & Kostaras, 2000) and buffering
their children from the negative impacts of PPD (Tannenbaum
& Forehand, 1994; Thomas, Forehand, & Neighbors, 1995).
In a review of six studies (n = 499 families) examining the
association between paternal depressive symptoms and parent-
child conflict (mean effect size of 0.20), non-depressed fathers
had more positive interactions with their 3- to 6-month-old in-
fants when compared to their depressed partners, a finding that
suggests that fathers whose partners are depressed may compen-
sate for the more negative maternal behaviour (Hossain et al.,
1994). Emerging evidence suggests that paternal depression has
a negative impact on the quality of father-infant interactions (J.
Goodman, 2004a). Depressed fathers demonstrate less pater-
nal warmth and more psychological control (Cummings et al.,
2005), and are significantly less engaged in literacy building ac-
tivities with their children (Paulson, Keefe, & Leiferman, 2009)
compared to non-depressed fathers.
IMPACT OF PPD ON INFANTS AND CHILDREN
Disturbances in mother-child interactions have been ob-
served at one-year postpartum even when mothers’ symptoms
of depression have remitted (Hipwell et al., 2000), and may re-
sult in more difficult child temperament (Hanington, Ramchan-
dani, & Stein, 2010), poor health (Casey, Goolsby, Berkowitz,
Frank, & Cook, 2004), decreased intellectual and motor devel-
opment, less secure attachments to their mothers, lower lev-
els of self-esteem (S. Goodman & Gotlib, 1999; Luoma et al.,
2001), and long-term behavioural problems in children (Ram-
chandani, Stein, Evans, & O
Connor, 2005). Evidence suggests
that mother-child interactions have more impact on children’s
self-esteem and emotional well-being, while father-child inter-
actions have more impact on children’s social competencies
(Conger, Patterson, & Ge, 1995; Kaisa & Jari-Erik, 2005). We
were unable to find any evidence of different domains of father-
versus mother-infant interaction relative to PPD, or research
looking specifically at the effects of PPD on siblings within the
family unit.
Health
Research suggests that infants of mothers with PPD are more
likely than those of non-depressed mothers to be abused or ne-
glected (Buist, 1998), diagnosed with failure to thrive (Drewett,
Blair, Emmett, & Emond, 2004), hospitalized with health is-
sues (Casey et al., 2004) such as asthma (Klinnert et al., 2001;
Kozyrskyj et al., 2008; Mrazek et al., 1999; Shalowitz et al.,
2006), and to have sleep-related problems (Field, 2010). Some
of these health effects have been attributed to depressed moth-
ers’ reduced use of age-appropriate safety practices, such as
 POSTPARTUM DEPRESSION AND ITS IMPACT ON THE FAMILY
failure to use car seats or leaving the child unattended (McLearn,
Minkovitz, Strobino, Marks, & Hou, 2006).
Cognitive Development
PPD negatively affects infant performance on measures of
cognitive development, learning tasks, and object permanence
(Cutrona & Troutman, 1986; Righetti-Veltema et al., 2003),
especially for boys (Cogill, Caplan, Alexandra, Robson, & Ku-
mar, 1986; L. Murray, 1992; Sharp et al., 1995), even when
controlling for maternal IQ (Hay et al., 2001; Lyons-Ruth, Zoll,
Connell, & Grunebaum, 1986). Disturbances in mother-child in-
teractions have been found despite mothers’ remission of PPD
symptoms (Stein et al., 1991). The long-term impacts of PPD on
children’s development have been demonstrated by lower vo-
cabulary scores in 5-year olds (Brennan et al., 2000), and lower
cognition scores in children ages seven (Kurstjens & Wolke,
2001) and 11 years (Hay et al., 2001).
Social-Emotional Development
The evidence is clear that PPD negatively influences
children’s social-emotional development (Grace, Evindar, &
Stewart, 2003; Hipwell, Ducournau, & Stein, 2005). In a clas-
sic meta-analysis of nine studies (n > 1200), PPD produced a
significant negative effect (d = .36 to .45) on children’s emo-
tional development (Beck, 1998). Rates of psychiatric disorders
among children of depressed parents are two to five times above
normal (Beardslee, Versage, & Gladstone, 1998), and the risk
associated with maternal depressive symptoms may be compa-
rable to that of paternal depressive symptoms (Phares, Duhig,
& Watkins, 2002). Impairments in attachment of infants and
children affected by PPD have been observed; two studies re-
vealed 70–80% of infants of depressed mothers were securely
attached versus 18–20% of infants of non-depressed mothers
(Cicchetti, Rogosch, & Toth, 2006; Teti, Gelfand, Messinger, &
Isabella, 1995). Avoidant attachment was observed in 12-month
and 18-month old infants of mothers who had PPD (Lyons-Ruth
et al., 1986; L. Murray, 1992). Infants of depressed mothers also
show reduced affective sharing, sociability to strangers, and re-
sponsiveness in interactions (Campbell, Cohn, & Myers, 1995;
Cohn & Tronick, 1987; Field, 1984; Field et al., 1985; Stanley
et al., 2004) when compared to infants of non-depressed moth-
ers. A meta-analysis of 33 studies found a significant relation-
ship between maternal depressive symptoms and child adjust-
ment problems (n = 4,561, mean effect size of 0.29–0.35) (Beck,
1999). Similar results were found in another meta-analysis of 17
studies of the relationship between paternal depressive symp-
toms and child internalizing problems, such as anxiety and de-
pression (n = 1,181; mean effect size = 0.19) (Kane & Garber,
2004).
Behavioral Development
Postpartum depression also has a notable impact on chil-
dren’s behavioral development. Four- to six-year-old children,
449
exposed to maternal depression at 18 months old, exhibited
more negative expressions, protests, and disruptive behaviours
during play interactions with their mothers compared to chil-
dren of non-depressed mothers (Alpern & Lyons-Ruth, 1993).
Pre-school and kindergarten aged children exposed to PPD dur-
ing infancy, particularly boys, are prone to more antisocial, ac-
tive, aggressive, hyperactive, and distractible behaviours (Elgar,
Curtis, McGrath, Waschbusch, & Stewart, 2003; Essex et al.,
2003; Sinclair, Murray, Stein, & Cooper, 1998). Kane and col-
leagues’ meta-analysis also revealed a relationship between pa-
ternal depressive symptoms and child externalizing problems
such as aggression and hyperactivity (n = 1,181; mean effect
size = 0.19) (Kane & Garber, 2004). Notably, males who were
exposed to both maternal depression and marital conflict during
the postpartum period were more likely to display externaliz-
ing behaviour problems like hyperactivity. At five years of age,
children whose mothers were depressed at two months of age
presented more behavioural disturbances, more physical activ-
ity, and less creative play, regardless of whether or not the mother
had recovered (L. Murray et al., 1999).
In summary, while the exact etiology of PPD remains un-
known, it is likely a result of biological factors and psychoso-
cial stressors. PPD may affect both mothers and fathers, causing
impaired interpersonal relationships and disturbances in fam-
ily functioning. Moreover, PPD causes significant perturbations
in parent-child relationships that, in turn, negatively influence
children’s cognitive, social-emotional, and behavioural devel-
opment as well as their physical health.
IMPLICATIONS FOR PSYCHIATRIC MENTAL HEALTH
NURSING PRACTICE AND POLICY IN FAMILY
INTERVENTION
Given the serious and long-term implications of PPD for
all members of the family, psychiatric mental health nursing
interventions need to address the needs of the whole family.
Addressing PPD as a family condition has significant implica-
tions for practice and requires an exploration of PPD screening,
interventions, and future research.
Screening Mothers and Fathers for PPD
Screening is key to the identification and diagnosis of PPD.
The Edinburgh Postnatal Depression Scale (EPDS) is brief 10-
question self-report survey that reflects mood over the past seven
days, and is the only screening tool normed for the identifica-
tion of PPD in both mothers and fathers. While the EPDS is
not intended for the diagnosis of PPD, it is well correlated with
physician diagnosis of depression (Cox, Holden, & Sagovsky,
1987). Universal screening with the EPDS for both maternal
and paternal depression in the postpartum period is advocated
(Field, 2010); however, best practice recommendations suggest
that fathers should be screened if mothers have a score of 12
or greater on the EPDS (Paulson & Bazemore, 2010). A score
greater than six on the EPDS is suggestive of symptoms of PPD
450 N. L. LETOURNEAU ET AL.
in fathers (Matthey, Barnett, Kavanagh, & Howie, 2001), com-
pared to scores of nine (i.e., corresponding to at-risk for PPD)
and 12 (corresponding to likely PPD) or greater for women
(Cox et al., 1987). The EPDS is effective in rapidly identify-
ing suicidal ideations; direct, but sensitive questions to explore
whether mothers have thoughts of self-harm or infanticide is
recommended in order to assess severity and risk (Barr, 2008).
If time or resources are a constraint, three key questions from
the EPDS have been demonstrated to have acceptable sensitiv-
ity (Kabir, Sheeder, & Kelly, 2008). Effective PPD screening,
however, will only impact clinical outcomes if there are systems
in place to ensure effective treatment and follow-up for families
affected by PPD.
PPD Interventions for Mother and Fathers
A body of literature has focused on the treatment of ma-
ternal symptoms of PPD. Known effective treatments for
PPD include psychotherapeutic or psychological support for
mothers provided by professionals, such as psychiatric mental
health nurses, physicians, or peer-professional support systems
(Dennis, 2004b; Dennis & Chung-Lee, 2006; Dennis & Le-
tourneau, 2007; Field, 2010) and, to some degree, medications
(e.g., SSRIs) (Arroll et al., 2009; Dennis, 2004b). To date, there
has been little intervention research targeting male partners of
mothers with PPD. In one study, Australian fathers who par-
ticipated in a 6-week group treatment program specifically de-
signed for male partners reported lowered levels of depression
and stress and higher levels of social support (Davey, Dziuraw-
iec, & O’Brien-Malone, 2006).
Relationship Interventions for PPD
While interventions to promote positive mother-infant
(Barnard, 1997) (Letourneau, 2001) and father-infant relation-
ships have been shown to be effective in normative samples
(Benzies, Magill-Evans, Harrison, MacPhail, & Kimak, 2008;
Magill-Evans, Harrison, Benzies, Gierl, & Kimak, 2007), the
degree to which these programs may be useful in families af-
fected by PPD in either the mother, father, or both has not been
widely investigated. Interventions that have focused exclusively
on mothers’ symptoms of depression have not demonstrated
improvements in maternal-infant relationship quality (Cooper,
Murray, & Halligan, 2010; Forman et al., 2007). Nonetheless,
interventions focused on enhancing the maternal-infant relation-
ship have been found to improve relationship quality, and more
intense forms may also ameliorate infant cognitive developmen-
tal outcomes (Poobalan et al., 2007). Limited evidence suggests
that interventions targeting maternal-infant relationships have a
variable impact on PPD symptoms. In a one-group pre/post-test
intervention targeting maternal-infant interactions, mothers’ de-
pressive symptoms did not improve despite improvements in re-
lationship quality (Jung, Short, Letourneau, & Andrews, 2007).
A recent randomized controlled trial of a peer-delivered version
of this same program found improvements in both groups, how-
ever, the control group improved more than the treatment group
on measures of depressive symptoms and relationship qual-
ity (Letourneau et al., 2011). Horowitz and colleagues (2001)
tested the efficacy of an interactive coaching intervention de-
signed to strengthen early dyadic relationships of infants and
mothers with depressive symptoms. While significantly higher
maternal-infant responsiveness was observed in the intervention
group there was no significant change in maternal mood asso-
ciated with the intervention (Horowitz et al., 2001). Similarly,
van Doesum and colleagues (2008) found that a randomized
controlled trial of an intervention aimed at improving depressed
mothers’ and infants’ attachment improved maternal sensitivity
and child infant responsiveness, but had no effect on maternal
depressive symptoms. To our knowledge, interventions designed
to enhance father-infant interaction in families affected by PPD
have not been tested, much less in psychiatric mental health
nursing settings. Even less is known about the impact of mari-
tal relationship-focused or couples interventions on maternal or
paternal depressive symptoms in the postpartum period.
In summary, the serious nature of PPD and its potentially
deleterious implications for all family members calls for urgent
attention. Strategies for intercession must include screening both
mothers and fathers for symptoms of depression as well as
treatment and follow-up for families affected by PPD.
RECOMMENDATIONS FOR FAMILY-CENTERED
INTERVENTIONS AND FUTURE RESEARCH
In clinical practice, fathers are often involved in assisting
mothers to recover from PPD (Kowalski & Roberts, 2000). How-
ever, interventions for PPD have focused primarily on treating
mothers (Dennis, 2003; Ray & Hodnett, 2001) and promoting
optimal mother-infant relationships (Armstrong, Fraser, Dadds,
& Morris, 1999; Brugha et al., 2000; Dennis, 2003; Gladstone
& Beardslee, 2002; Reid, Glazener, Murray, & Taylor, 2002;
Stamp, Williams, & Crowther, 1995). Only rarely have inter-
ventions focused on the mother-child-father triad, the couple, or
included fathers in support programs for mothers. Attempts to
reduce or prevent depressive symptoms in mothers, and change
maternal-infant interactions and improve outcomes for children
of mothers with PPD, have met with limited success (Dennis,
2004a; Dennis, 2004b; Forman et al., 2007). Enhancing the role
of fathers in therapeutic interventions may well be an important
support strategy for reducing the symptoms of maternal PPD,
preventing and treating paternal depression, and improving de-
velopmental outcomes for children (Kabir et al., 2008; Watson
& Stewart, 2003). Investigations of the impact of relationship-
focused (i.e., couple and parent-infant) therapies are also war-
ranted.
Family-Centered Approaches to PPD
Including fathers in family-centered interventions for PPD is
critical in addressing the issue of optimizing child development.
Evidence is accumulating that fathers play an important role in
 POSTPARTUM DEPRESSION AND ITS IMPACT ON THE FAMILY
their partner’s recovery from PPD, either by exacerbating the
risk of psychopathology in their children (S. Goodman et al.,
1993) or in buffering them from the adverse effects of maternal
depression (Conrad & Hammen, 1989). (Letourneau, Duffett-
Leger, & Salamani, 2010). Since fathers can promote healthy
child development by compensating for mothers’ less than opti-
mal interactions with their infants, serve as positive role models
for children, and provide respite for mothers, fathers ought to
be regarded as an essential part of family treatment for PPD in
psychiatric mental health nursing settings (Hossain et al., 1994;
Watson & Stewart, 2005a, 2005b)
Family-centered care for PPD may be provided using a mul-
tidisciplinary service model (McKay, Shaver-Hast, Sharnoff,
Warren, & Wright, 2009). In this model, families follow a stan-
dard progression through treatment, beginning with the moth-
ers entering the clinic service to receive treatment that may be
comprised of medication, interpersonal psychotherapy, and/or
cognitive behavioral therapy (see Figure 1). Mothers’ treatment
focuses on improving sleep, nutrition, and social support and re-
ducing disturbing and intrusive thoughts. Mothers are reported
to improve within six to nine months. During this period, the fo-
cus of therapy gradually changes from a symptoms-amelioration
approach to one focused on optimizing maternal-infant interac-
tion. After maternal symptoms and the maternal-infant relation-
ship are stabilized, then the father is involved in therapeutic work
on any problems that remain. This approach, while it represents
a leap forward in family-based therapy for mothers, fathers, and
infants affected by depression, may still inadequately address
the needs of fathers for support, or the inclusion of fathers in
the optimization of parent-infant relationships (Magill-Evans,
FIGURE 1. Proposed Decision Tree for Screening and Treatment of Families Affected by PPD.
451
Harrison, Rempel, & Slater, 2006). Additionally, the promise of
couples’ therapy in helping to address or resolve marital conflict
is not included in McKay et al.’s model. Future research could
address this gap.
Another innovative example of family care for PPD is the
Australian Institute of Family Studies’ PEPP Program (Psycho-
Educational Program for Parents) which is a mental health
promotion intervention for fathers, mothers, and their infants
(Fisher, 2006). The aim of the program is to address two under-
recognized risk factors for postpartum psychological distur-
bance: (1) the quality of relationship between mothers and fa-
thers and, (2) management of infant crying, sleep, and settling.
Together these strategies are intended to increase parental aware-
ness of infant developmental needs and parental care-taking
skills, thereby leading to reduced infant crying, reduced infant
resistance to soothing and settling, improved parent-infant inter-
action, and increased parental confidence in and enjoyment of
infant care. Another such project, the Development of a Home-
Based Family Treatment for Postpartum Depression, is currently
underway at Brown University in Rhode Island (Battle, 2008).
Interventions Targeting Couples Affected by PPD
Little evidence was found to address interventions targeting
depressed single parent or non-traditional marital family struc-
tures consisting of depressed parents of gay, lesbian, bisexual, or
transgendered orientations. As such, evidence was derived from
studies of traditional heterosexually oriented marital couples.
Given the bi-directional relationship between marital dysfunc-
tion and parental depression, quality of marital relationships is
452 N. L. LETOURNEAU ET AL.
an area worthy of further exploration and intervention. While
marital quality is positively associated with parent-infant rela-
tionship quality (Belsky, Youngblade, Rovine, & Volling, 1991;
Osborne & Fincham, 1996), unresolved marital conflict may
be a better predictor of poor child outcomes than maternal de-
pression. Marital conflict affects infants and children through
the chronic stress caused by witnessing conflict, negative re-
inforcement (e.g., acting out to interrupt conflict between par-
ents), or modeling aggressive behaviour seen at home (Elgar,
McGrath, Waschbusch, Stewart, & Curtis, 2004). Conversely, a
satisfying marital relationship is associated with greater parental
well-being, more positive parental attitude towards the infant
and the parenting role, greater involvement with and sensitiv-
ity to the infant, and increased sense of competence in infant
care (Areias, Kumar, Barros, & Figueiredo, 1996; Broom, 1998;
Deater-Deckard, Pickering, Dunn, & Golding, 1998).
SUPPORT PROGRAMS FOR FATHERS AND MOTHERS
Mothers report social support needs including information
(e.g., about PPD symptoms and prognosis), emotional support
(e.g., listening), and affirmational (e.g., reassurance of normal-
ity) support (Letourneau et al., 2007). As mothers report that
fathers are a key source of support (Letourneau et al., 2007)
and that fathers would be more effective if they knew more
about PPD and how to assist their partners’ recovery (George,
1996) (Letourneau et al., 2007), fathers ought to be involved
in mothers’ care decisions and therapies (Letourneau, Dennis,
Stewart, Duffett-Leger, & Tryphonopoulos, 2011). Recogniz-
ing the value of fathers in interventions for mothers does not
come without caveats; fathers may be ill themselves, chroni-
cally overburdened with caring for their partner and child(ren),
fatigued, or in marital turmoil. While little is known about ef-
fective therapies for fathers with depression in the postpartum
period, clearly the importance of fathers to marital quality and
mothers’ and children’s health suggests that focusing on re-
turning fathers to mental wellness ought to be an intervention
priority. Interventions for fathers should address their informa-
tional, emotional, and affirmational support needs (Letourneau
et al., 2012). Interventionists are advised to assess and talk with
fathers to determine the best way to involve them in mothers’
treatment.
CONCLUSION
In summary, PPD is related to increased social isolation, so-
cial support deficits, increased marital discord, reduced quality
of maternal-infant interactions, and negative perceptions of in-
fant behaviors that, in turn, have been linked to reductions in
infant health, attachment insecurity, social-emotional develop-
ment, and cognitive development. Clearly, PPD exacts social
costs borne by women, their families, and children and, by
extension, society. Using a systematic approach to the identifi-
cation and treatment of PPD, for both partners and parent-infant
relationships, is strongly recommended in psychiatric mental
health nursing practice.
Declaration of interest: The author reports no conflicts of
interest. The author alone is responsible for the content and
writing of the paper.
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