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Perinatal depression in men: fathers needs remain unmet

As research once again highlights high rates of paternal perinatal depression, practitioners and charities discuss how their needs may be identified and met
Kin Ly
Assistant editor

New research has added to a growing body of evidence that rates of postnatal and antenatal depression in fathers are higher than many realise, raising concerns that these problems are not being picked up by healthcare professionals through their contact with families. In a meta-analysis published in the Journal of the American Medical Association in May,1 US researchers identified 43 relevant studies involving 28 004 participants from January 1980 to October 2009, and found depression to be evident in about 10% of fathers between the first trimester and the first year postpartum (see Clinical papers on page 38). James Paulson, one of the researchers and an associate professor at Eastern Virginia Medical School, highlights possible reasons as to why cases of paternal depression are not well detected: My impression has been that healthcare professionals who care for families during pregnancy and postpartum are focused primarily on mother and baby. Father is not typically considered, which is almost certainly contributed to by his frequent absence during these early appointments. Moreover, there are no established professional guidelines for screening fathers for depression, and this deficiency extends to most healthcare professionals not even knowing what screening instrument ought to be used. He adds: The elevated risk for depression during pregnancy and postpartum has not been clearly documented and is not widely known by most health educators and healthcare professionals. Additionally, there is evidence, at least in the US, that men tend to underutilise healthcare services generally, and are particularly hesitant to speak with a doctor about depression or other mental health concerns.

Earlier research, part of the Avon Longitudinal Study of Parents and Children, had found that depression in fathers at this time can have an impact on the early behavioural and emotional development of children,2 which underlines the importance of addressing this issue to the health and wellbeing of the whole family.

Excluded fathers Many healthcare professionals, including health visitors, have raised similar points as key issues that make identifying antenatal and postnatal depression in fathers challenging.

He stresses the impact on the family if cases of paternal depression are left undiagnosed: Clinical depression runs at about 10% in fathers according to research over the last few years. Depression in fathers is a huge burden on mothers and families, just as maternal depression is. Indeed, depression is a contagious illness, and where both parents are depressed, the family and the baby are highly vulnerable. Depression in fathers can manifest itself in different ways, for example, withdrawal into work or obsessive solitary activity like computer games.

Cultural reluctance Although services might exclude or not involve fathers, the charity Mind asserts that there is also a cultural problem at work, and that early intervention is the key to addressing this. Minds head of information Bridget OConnell states: Men are notoriously reluctant to go to the doctor for any kind of health issue, let alone to explore emotional and mental health. Rather than putting the emphasis on practitioners picking up on the problem, work needs to be done at an earlier stage to ensure that men are prepared for the stresses and strains, and so they know that if there is a problem, then they can go to their doctor or health visitor in the same way their partners can. It is known that men think about their health when they become a father, and so this can be a key time for healthcare professionals to work with men. Involving fathers early on Fathers To Be founder Patrick Houser reinforces the importance of involving fathers during the antenatal period: If you think childhood begins at birth, then you are nine months too late. If the parents are under-supported or under-resourced during the pregnancy, then the child and the parents are disadvantaged and the future of the family is at risk. He adds: Caring for a child starts during the mothers pregnancy, and for the majority of mothers a significant factor for a successful pregnancy, birth and for initiating and sustaining breastfeeding is the care provided by the father. We have an issue where fathers are not provided with proper antenatal preparation. Fathers can be virtually ignored. If the father is informed and properly educated, then everyone benefits. Patrick states that it is essential to involve fathers during the delivery of the baby and stresses that maternity services and healthcare professionals must be equipped with the skills to do this: In 1975, a piece of research suggested that fathers spent only 15 minutes a day with their children. They did the research again in 1995 and found that fathers were spending two hours a day with their children. During that time, fathers entered the birthing room. Many different hormones are stimulated in man when he is present at the birth, and if during this time he feels safe and included
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and also goes skin to skin with the baby, then he is more likely to develop that instant connection with his newborn. He adds: It is more challenging for fathers to develop that instant connection, because they do not have that biological

Work needs to be done at an earlier stage to ensure that men are prepared for the stresses and strains
and physical connection that the mother has carrying the baby, and part of that postnatal depression is partly due to not having that chance to connect.

and postnatal services that are free at the point of delivery. Evidence continues to build of fathers needs that should be identified and addressed in the antenatal and postnatal periods, both for their own health and wellbeing and also for that of the rest of the family. However, there appears to be a gap in the awareness or resources required for many practitioners to be able to recognise perinatal depression in fathers and the wider role that it may play. This is especially so when all services are underresourced and threatened by cuts, and it remains to be seen whether government promises will be backed by action.

1 Paulson J, Bazemore S. Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. Journal of the American Medical Association, 2010; 303(19): 1961-9. 2 Ramchandani P, Stein A, Evans J, OConnor TG; ALSPAC study team. Paternal depression in the postnatal period and child development: a prospective population study. Lancet, 2005; 365(9478): 2201-5.

It is not a requirement to do the same type of perinatal mental health assessment with the father
Unite/CPHVA Health Visitor Forum chair Maggie Fisher states: It is not a requirement to do the same type of perinatal mental health assessment with the father as we do with the mother. Since the majority health visitors tend to work nine to five, this means that we often miss the father, who may be working between those hours. Duncan Fisher, director of parenting charity Kids in the Middle and the former chief executive officer of the Fatherhood Institute, agrees: The NHS only views mothers as the client and yet depression, whether in mother of father, is fundamentally a family issue. The causes, the debilitating impacts and the solutions to depression most often lie within families and research bears this out approaches that engage with the family as a whole are considerably more effective.

Low resources However, although it is important to conduct postnatal mental health assessments with both parents, Maggie says that the continued lack of resources is having a detrimental impact on how these assessments are conducted: The problem is that we have so little contact with parents now. In some trusts, these assessments are being done by community staff nurses or even over the phone. It is increasingly becoming a targeted assessment instead of a universal assessment done between one to six weeks and six weeks to six months. Practitioners are often only assessing the mothers and not thinking about the fathers mental health needs. Commissioners need to understand that fathers must also be assessed. However, there are issues around the effectiveness of the Whooley questions to identify parents who need further assessment. Maggie states: These questions do not differentiate anxiety from depression, and the big problem is that not all parents answer them honestly particularly when asked by a health worker who they do not have a trusting relationship with, or if it is done over the phone or by post.
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Shared parenting In its jointly published programme, the coalition government has promised to encourage shared parenting from the earliest stages of pregnancy, and many will be watching to see if this has an effect. Duncan Fisher comments: This is profoundly radical, because it flies in the face of how the whole of maternal and baby health care is structured. But it is a great opportunity because as soon as we start engaging with both parents, our engagement with postnatal depression will improve markedly. Maggie Fisher states that this promise must be delivered and that services must be tailored to reach out to fathers: There is something fundamental about involving fathers very early on, as research indicates. The government needs to fulfil its promise and ensure that both mother and father are equally targeted. The service must be accessible to fathers. For example, assessments could be offered during evenings and weekends. She adds: In some parts of the country, parents do not have access to free antenatal classes. A survey of 3500 mothers by Netmums and the RCM in 2009 found that 30% of mothers were not offered free antenatal classes. If we want to target the hard to reach, then there needs to be a universal service offering a full range of antenatal