Although watching your children grow into healthy and happy adults is one of the most rewarding journeys, it also is the most stressful and exhausting role one would fill. Parenting is a significant life transition, which increases the vulnerability to psychological distress, often leading to the onset or relapse of psychiatric disorders, mainly depression, for both parents.
Postpartum depression in women has been studied extensively and is a well-known risk factor for poor physical and psychological child outcomes.[1] However, the peculiar demands of raising a child can take a toll on both parents’ mental health. Recent literature suggests that depressed fathers are less likely to indulge in pleasant parent-child interaction, e.g., reading, teaching, playing, etc., and are more likely to abuse or neglect their children. Consequently, the children of depressed fathers are more likely to have emotional, cognitive, and behavioral problems. Hence, it is imperative to recognize paternal depression at the earliest for appropriate preventive and remedial measures.
However, paternal perinatal depression (PPND) is not an official psychiatric disorder as per the Diagnostic and Statistical Manual of Mental Disorders-5, and it is also not widely acknowledged or researched even in developed countries. Thus, the awareness, consequences, and remedial measures in developing countries like India are far from adequate. Nevertheless, paternal mental health during the same period has been gaining attention lately, given the high incidence of psychiatric morbidity. This short communication aims to provide the reader a road map for a better understanding of paternal depression and its prevention in the global south.
PREVALENCE
The mental health of fathers has been studied inadequately compared to mothers, but there have been encouraging advances in the past decade. A meta-analysis (2010) including 43 studies involving 28,004 participants studying the prenatal and postpartum depression in fathers reported that the peak incidence of depression (25.6%) in fathers was between 3 and 6 months after the birth of the child, though 10.4% of fathers were found to be depressed even prenatally.[2] In a recent meta-analysis, Cameron et al. (2016) reported 8.4% depression rate in fathers during pregnancy and the postpartum period: With the highest prevalence of 13% between 3 and 6 months of the postpartum.[3] These variations in the prevalence could be attributed to the use of different psychometric tools, different assessment methods (self-report measures tend to over-represent while clinical interviews tend to underrepresent), gender differences in symptom presentation, cultural biases, e.g., conflicting interpretations of depressive symptoms, social acceptance of mental health problems or divergent expectations concerning paternal infant care responsibilities.
The most important risk factors associated with PPND correlates with depressive symptoms in the partner, poor interpersonal relations with spouse and inadequate social support. Prenatal maternal depression is considered to be the most significant predictor for postnatal depression in men.[4]
There are other risk factors that include a history of severe depression in the past, prenatal depression/anxiety, partner prenatal depression, lower educational level, paternal unemployment, marital conflicts, and having other children. Fathers with low income, single dads, stay-at-home dads and young dads are especially vulnerable to anxiety and depression. There have been changing sociocultural norms in the last 2–3 decades with significant ideological, technological, social, and economic changes. The role of women in society is also changing, with a majority of them working full time, shorter maternity leaves and quick return to the jobs, nuclear families, higher divorce rates, etc., forcing fathers to take on responsibilities for which they were not very well prepared.
SIGNS AND SYMPTOMS
Men and women express and cope with their affective symptoms in different ways. The clinical presentation of paternal depression can be varied, ranging from unwarranted anger outbursts, marked irritability, impulsivity, avoidance, social isolation from loved ones, emotional rigidity, and resorting to substance use. Depressive symptoms are often comorbid with anxiety and obsessive disorders, and a range of somatic symptoms, along with alcohol and drug abuse, which can mask the main symptoms of paternal depression.[5] The most frequent behavioral abnormalities are (a) rage attacks and aggressive behaviors toward the infant and the partner; (b) avoidance and loss of interest in family life, with increased engagement in work and leisure activities; (c) extramarital affairs; (d) compulsive exercise or sexual activities; (e) excessive use of videogames and internet (e.g., compulsive chatting, pornography, and sex site usage, internet addiction disorder) or gambling.[6] Sexual problems and dysfunctions can also arise in the couples due to relational, psychological (depressed mood, and desire or excitement disorders), and physiological (genital pain and dyspareunia) factors.[7]
IMPLICATIONS
There is a significant association between maternal depression and PPND, such that maternal depression is a strong predictor of paternal depression while paternal depression incrementally increases the risk of worsening of maternal depression. Gutierrez-Galve, Leticia, et al. (2019) investigated the association between paternal depression and offspring depression at 18 years of age and reported increased risk of depression symptoms in the offspring of fathers who had depression during the postnatal period.[8] Furthermore, it has been shown that the risk for offspring mood or anxiety disorders did not differ according to whether the affected parent was the mother or the father and that children were at significantly greater risk when both parents were depressed. Hence, it becomes crucial to recognize the existence of an interaction between the psychological states of both members of the couple to provide successful interventions.[9] Evidence is accumulating regarding the impact of paternal depression on child development and later psychosocial outcomes. Studies with paternal depression in early childhood have described undesirable aggressive or harsh disciplinary parenting behaviors.[10] PPND tends to negatively affect parental warmth, healthy engagement behaviors such as reading and other positive parent-child interactions, and significant expressive language delay in children.[1011] Children with paternal depression also scored high on scores of hyperactivity, oppositional defiant/conduct disorder and peer group problems.[12] There is a marked depreciation in marital quality during the transition to parenthood, which only gets compounded with the co-occurrence of depression in either partner leading to crippling of the family functioning.[13]
RECOMMENDATIONS
The available educational materials, screening procedures, and interventions focus primarily on postpartum depression in mothers, while information regarding paternal depression is almost nonexistent. The stereotypical concepts of masculinity, feelings of shame, and stigmatization regarding paternal depression often prevent men from seeking help. Rather than asking for help, they endure stress and discomfort through “externalizing” strategies, such as smoking, drinking alcohol, drugs, gambling, and compulsively engaging in sports or sexual activities. We propose few recommendations as follows to address the issue.
Awareness
In a pilot study designed to evaluate the support needs of the fathers suffering from paternal depression, the participants reported an information gap regarding PPND and expressed difficulty in accessing information about the same.[14] Hence, it is crucial to raise awareness by mass media campaigns and make couples and society in general aware about this entity. Providing information on prevalence, symptomatology, and risk factors of PPND might reduce the stigmatization for men dealing with this issue. It is also appropriate to inform mothers during their antenatal visits about the possibility that their partner can suffer from an affective disorder. Organizing meetings with parents and distributing informative material in consultation centers and hospitals, and disseminating information through the internet and the media could be helpful. Moreover, a special mention needs to be made that emotional distress in fathers often manifests in the form of behavioral disorders that can mask depressive symptoms. Increased awareness and knowledge of PPND could facilitate its identification and promote early and adequate treatment.
Screening
There is a need for active screening for timely and effective management of PPND. However, there are currently no screening tools specific to evaluate perinatal affective disorders in males. The routine postnatal well-baby clinic visits can be utilized for screening purposes under the supervision of a Childcare social worker and psychiatric social worker. Self-administered screening questionnaires such as the Edinburgh Postnatal Depression Scale can serve as a screening tool for both parents.[914] However, for an accurate assessment of male affective disorders, assessment tools need to be specifically tailored catering for gender differences and the use of externalizing strategies meriting better sensitivity and reliability. Recently, a new screening tool for paternal affective symptoms, the Perinatal Assessment of Paternal Affectivity (PAPA), has been proposed.[15] The questionnaire investigates several symptom dimensions, including anxiety, depressive symptoms, perceived stress, somatic symptoms, hypochondria, addictive disorders (smoking, drinking alcohol, taking drugs, gambling, and compulsive use of the internet), performing risky physical activities, and sleep problems. The PAPA is a screening tool whose purpose is to identify vulnerability for affective disorders in fathers rather than a diagnostic instrument. Another promising technique to screen for PPND is the Child Adult Relationship Experimental (CARE) index based on audio-visual recording-based techniques.[16] It consists of a 3–5 min video recording of the spontaneous relationship between child and parents and evaluates parental sensitivities toward infant needs.
Self-help groups
The perceived availability of social support in the face of a stressful event may lead to a benign appraisal of the situation, thereby preventing a cascade of ensuing negative emotional and behavioral responses. A pilot study found a lack of information regarding PPND resources and fear of the stigma associated with PPND as the most commonly reported barriers impeding access to support for fathers.[14] The study further revealed that even when fathers identified support sources, they were often ignored by the health professionals. Thus, until a practical and accessible supportive intervention is not founded for the fathers, social support groups can be instrumental.
Multispecialty approach
Paternal depression should be considered within a systemic family perspective, bearing in mind that during the entire perinatal period, the mental state of both the parents influences each other. Thus, when one parent is depressed, it is mandatory to carefully consider the possibility that the partner could also experience mood disorders. Thus, the first contact professionals in obstetrics and pediatrics should be prepared to consider not only the physical health of both parents but also mental health issues and to be aware of the early symptoms of an affective disorder.[17] Thus, a comprehensive and multispecialty approach involving pediatricians, family physicians, and psychiatric social workers to monitor paternal mental health can enhance screening and ensure timely referrals to the psychiatrist. It is recommended that a screening tool should be routinely included in the evaluation during antenatal and postnatal visits.[18]
Prevention and treatment
Parent training techniques during the antenatal and perinatal periods utilizing psychoeducational, psychodynamic, and cognitive-behavioral techniques are recommended preventive strategies for all couples. The high-risk families (adolescent parents, abusive families, drug addicts, children with physical illnesses, etc.) should be identified and prioritized for interventions. Psychotherapeutic and pharmacologic interventions are warranted when the individual/couple shows significant distress, potentially jeopardizing the family relationships. The most valuable interventions in the perinatal period are the audio-visual recordings of the interaction between parents and children. There are various video-feedback protocols, e.g., Systematic Training in Effective and Enjoyable Parenting, video-feedback intervention to promote positive parenting, CARE Index video feedback.[19] The videos are recorded and watched along with the therapist's comments, suggestions, and encouragement promoting the parent's sensitivity, enabling them to adopt a more appropriate attitude toward the child and the partner. Another approach is “conscious parenting” based on mindfulness-based interventions with an emphasis on present moment attentiveness, nonjudgmental acceptance, emotional awareness, nonreactivity, self-regulation of the parental relationship, and compassion for oneself and for one's child.[20]
CONCLUSION
A significant number of expecting and new fathers experience depression during the prenatal and postpartum periods. Paternal depression affects not only the overall development of the child but also the spousal relationship and the family unit as a whole. Enhanced awareness regarding the prevalence, symptomatology, and prevention of paternal depression will help the fathers/couples and facilitate a psychologically healthier next generation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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