Should men be screened and treated for postnatal depression?

Keywords::

• depression
• fathers
• paternal
• postpartum
• screening
• treatment

Although much is known about postpartum maternal depression and its effects on the child, little is known about the extent of the problem in fathers, the risk factors of them developing postpartum depression and its effect on the family. This article will present an overview of the prevalence of the problem in fathers, how these figures compare with the rates of depression in mothers, the factors that predispose fathers to developing depression in the postpartum period and the effect on child development. The obvious clinical implications of this issue are whether fathers should be screened for depression during the pre- and post-natal period, and what are the most appropriate treatments that can be offered to those identified with the disorder?

A recent systematic review of depression in parents combined data from 43 studies to estimate an overall prevalence of paternal depression in the prenatal and postpartum period of 10.4%. This rose to 26% at 3–6 months after the birth of the baby [1]. These figures are considerably higher than the 4.8% rate of depression that has been estimated in general population prevalence studies conducted in the USA in men of this age group [2]. The overall prevalence of maternal depression estimated from these 43 studies was 23.8%, and this rose to 41.6% during the 3–6 month postpartum period [1]. There was a moderate correlation between depression in fathers and mothers, thus suggesting a relationship between the mood disorders of both parents during this period of vulnerability. This meta-analysis is the best attempt to bring together data from a whole range of studies across the world. However, it was limited by the heterogeneous nature of studies included in the review, which assessed depression using a range of different instruments, over different time periods and in relatively small samples of fathers who were recruited from a range of situations, many of which were not strongly population-based. Nevertheless, there were two large studies included in this review with just over 5000 [3] and 10,000 [4] fathers. The first was conducted in the USA and assessed paternal depression in 5089 fathers 9 months after the birth of the baby using a standard depression scale inventory, and reported rates of depression of 10% [3]. The second study was conducted in the UK based on 10,975 fathers who were initially assessed at 4.5 months during the gestation period for depression using an established instrument that has been previously used to screen mothers in the pre- and post-natal period for depression. These assessments were then repeated at 2, 8 and 21 months after the birth of the baby. The rates of depression during these time periods were within the range of 3.4 to 3.9% [4]. These figures compare favorably with the reported level of incident depression of 3.6% that was recently reported from a cohort of 86,957 fathers seen in UK general practice in the first year after the birth of the baby [5]. Some of the major risk factors for paternal depression in the postpartum period in this cohort were a previous established history of depression, lower parental age at the birth of the child (i.e., fathers below the age of 25 years were particularly vulnerable) and higher social deprivation [5].

Whilst the debate on the level of postpartum depression in fathers continues, it is essential that clinicians consider the immediate and long-term effects of parental depression on child development. The only independent evaluation of the effect of both paternal and maternal depression on child development, which assessed the effects of both fathers’ and mothers’ postpartum depression at 8 weeks on the children’s development at 3.5 years of age, identified an increased risk of hyperactivity and conduct behavior problems in children of fathers with depression. These effects persisted after controlling for possible confounders, such as social class, parental education, maternal depression and persistent paternal depression at 21 months after the birth of the child [4], and the effects were more pronounced in boys than girls. Within the same cohort, similar behavioral problems were also observed in children at 3.5 years of age in mothers with postpartum depression at 8 weeks, but there were no differential effects on boys and girls, as observed with fathers. Other cross-sectional studies have demonstrated that paternal depression in the postpartum period is associated with a difficult/fussy infant temperament at 6 months [6]. Furthermore, depression in the fathers of children aged 4–6 years is associated with higher levels of conduct and hyperactivity behavior problems and a greater number of general practice consultations for speech and language difficulties [7,8]. Several hypotheses can be generated on the mechanistic effects of depression on child development [9]. For example, paternal depression may cause developmental and behavioral problems in children, either directly through how fathers interact with their children, as has been previously demonstrated with mothers who have postpartum depression, via relationship discord between the mothers and fathers, and/or by alcohol misuse by fathers. Additionally, higher consultation rates among children of depressed fathers with problems pertaining to speech and language difficulties could be explained by paternal anxiety and a negative perception of the child by the father. Finally, genetic factors could play an important role, but strong evidence to support this is currently lacking.

Paternal postpartum depression is now an established clinical problem and the effects on child behavior can be observed as early as at 6 months of age and can become even more established at 3–4 years of age. In clinical practice, one encounters several problems when trying to deal with this issue. Men in general are known to consult less frequently than women in general practice, and those with depression are less likely than women to seek help from their doctors [10,11]. Hence, in many instances, fathers with postpartum depression will go unnoticed as they may be reluctant to approach the doctors and discuss their emotions with them. The National Institute of Clinical Excellence (NICE) in the UK has recently recommended routine pre- and post-natal screening for depression in mothers [101]. In light of the vulnerability of fathers developing depression during the postpartum period, their failure to seek help and the possible effects of the father’s depressed mood on the mother and the baby suggests that there is a need to extend this screening to both parents. Younger fathers, those with a history of depression and of lower socioeconomic circumstances are a higher risk and merit specific attention [5]. Screening of both parents will allow early identification of depression and in particular will reach a group of fathers who would have avoided contact with the doctor. Moreover, it serves as the first step towards managing depression within the family unit rather than the current focus on one parent. Further research on the effects of the trajectory of paternal depression, either on its own or in combination with maternal depression, on child outcomes could go a long way to informing us on when might be the best time to screen for depression. There is also a need to tease out the individual and combined effects of paternal and maternal depression on child development [5]. However, until such evidence is available, there remains a strong case for extending the NICE guidance as it currently stands to both parents.

There is a dearth of knowledge on the effectiveness of treatments for postpartum paternal depression. The general evidence on treatment for depression would suggest that men with depression could benefit from pharmacological therapies or psychological interventions [102]. However, the evidence of the effects of such treatments on child outcomes needs further evaluation. For example, would the treatment of fathers with antidepressant drugs in the postpartum period lead to a reduction in the behavioral and developmental problems in their children when compared with fathers who do not receive such treatments. A recent systematic review of studies that examined various treatments of parental depression demonstrated some beneficial effects on child adjustment; however, only two of the ten studies that were part of the review evaluated paternal effects and neither reported separate data on fathers [12]. Clearer evidence on the mechanism of the effects of postnatal depression in fathers on the family (i.e., the mother and children) will build the theoretical basis of treatments during the postpartum period. For example, if impaired parenting is indeed one of the mechanisms through which paternal depression affects children, then treatments that focus on developing parenting skills can enhance positive parenting, thus minimizing adverse outcomes in children. Similarly, if paternal low mood associated with depression is responsible for developing a negative view of oneself and the future, thus leading to poor engagement with the child, it would seem appropriate to consider antidepressant therapy or cognitive behavior therapy to alter the father’s mood. Several studies of cognitive behavior therapy among depressed mothers have produced varying effects on child development with the exception of one study, which did demonstrate some improvement in the mother–infant child relationships [13,14]. There is a pressing need to conduct similar treatment evaluations directed at fathers with postpartum depression. However, since both parents are vulnerable to depression from early conception to after the birth of the child, the joint management of both fathers and mothers as a family unit must also be seriously considered. Screening for depression would be the first step towards normalizing depression for both parents and may facilitate better engagement in treatment programs when a problem is identified. Further research is required on the role of interpersonal therapies, particularly those that enhance the relationship between the couple and/or the interaction between the parents and their child and/or communication within the family. Such approaches would address some of the key factors linked to parental depression and could hence positively influence child behavior. Future research should focus on developing theory-based interventions delivered jointly to both parents. Treatments that address some of the key mechanisms that contribute to parental depression and adversely affect child development may indeed be the future approach of dealing with parental depression.

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.