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EVIDENCE SYNTHESES

Fathers’ experiences of depression during the perinatal period: a qualitative systematic review

Davenport, Caroline1; Lambie, John1; Owen, Craig1; Swami, Viren1,2

Author Information
doi: 10.11124/JBIES-21-00365
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Abstract

Summary of Findings

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Introduction

In the United Kingdom (UK), it is recommended that all women be screened for perinatal mental health problems1 (ie, the period spanning pregnancy through to one year after birth2), but there is no universal approach for fathers. Based on systematic reviews of international studies, paternal perinatal depression has a slightly lower estimated prevalence (8.4%3) than maternal perinatal depression (11.9%4). Whilst it is not possible to quantify the exact number of men who become fathers in a given year, this prevalence is concerning for two reasons: i) nearly one-tenth of fathers have depression, and ii) this potentially affects not only fathers, but also their partners and infants.

This period beginning with pregnancy is relevant for men, since fathers experience the highest levels of psychological symptoms in pregnancy.5 Incidence of paternal depression is considered highest in the first year after birth,6 suggesting the perinatal period is specifically worthy of attention. Furthermore, there are wider consequences of paternal perinatal depression. The condition increases suicide risk in fathers7 and reduces positive father–infant interaction.8 Paternal perinatal depression is also associated with behavioral problems in children.9,10 There are also relational impacts of paternal depression. Paternal postnatal depression (PND) has been associated with maternal PND11-13 and, concerningly, is also linked with negative mother–infant interactions.8 To improve outcomes for the entire family unit—that is, to support fathers with their mental health and thus limit the effects on their wider families—there is a need to understand paternal perinatal depression in the perinatal period from a father's perspective.

Existing systematic reviews offer some knowledge on wider father mental health. One qualitative review identified factors influencing fathers’ mental health including fatherhood identity, role challenges, and negative feelings and fear.14 There are also other published reviews, including a narrative review of fathers’ support experiences,15 and a review of interventions for paternal mental illness.16 Importantly, however, these reviews did not explore the paternal lived experience of paternal perinatal depression specifically.

There are limited existing findings on paternal experiences of depression. For example, one recent systematic review integrated current evidence on maternal and paternal lived experiences of postpartum depression (PPD).17 Yet, whilst findings on mothers were rich, only two papers regarding fathers were included in the review,18,19 producing only two synthesized findings: “depressed fathers experience disappointment arising from perceived imbalances between their support needs and the support they get from their partner and significant others”; and “depressed fathers are more imbalanced after childbirth than fathers who are not suffering from PPD.”17(p.1731) This demonstrates a limitation in the quantity of qualitative research around paternal depression.

There are also methodological barriers to understanding these phenomena. Both papers included in the aforementioned review were partly based on parents having depressive symptoms as determined using the Edinburgh Postnatal Depression Scale (EPDS).17 This scale has been validated for use with fathers,20 but there are limitations to using this tool to identify depression in men. Scholars have suggested that men with depression present atypically,21 with one study finding that fathers commonly experienced anger alongside depression in the postpartum period.22 As such, use of the EPDS alone potentially excludes studies where men identify as having anger or other symptoms. Notably, one study also used the Gotland Male Depression Scale (GMDS), which scores for male-typical behaviors, including aggression and irritability, and this has been validated in Sweden for alcohol use disorder23; however, this is not routinely used to screen fathers in the UK. To produce a review that reflects these gendered reactions to depression experienced by fathers in the perinatal period, our search strategy also includes mental distress and symptoms of co-existing depression in men, such as, but not limited to, anger.22 Depression was also considered to include low mood, but also wider negative emotions. There are differences between the conceptualization of depression between diagnostic manuals (eg, the DSM-5 and ICD-10), assessment tools (eg, the EPDS and GMDS), and how the layperson experiences it. This informed the use of wider emotions in the present search.

Research has demonstrated poor mental health literacy around depression in men in general,24 but more recently around paternal perinatal depression,25 suggesting the typical terminology used around the condition (eg, PND) may not be something many men identify with. One study showed that men have substantively better understanding and use of the term “depression,”24 which informed the use of “depression,” rather than postnatal or perinatal depression in the main systematic review question, but also the protocol sub-questions.

A qualitative systematic review methodology was used to answer the research question using the JBI approach.26 This is an appropriate method in health care topics, has well-established guidance,27 and is suited to investigate human experiences.28 To ensure originality, an a priori protocol was registered with PROSPERO (CRD42021245894). A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted in March 2021 and no current or in-progress systematic reviews on the topic were identified.

The primary objective of the review was to understand fathers’ experiences of perinatal depression. Sub-objectives were to develop an insight into, and evaluate, fathers’ recognition and understanding of perinatal depression, the emotions they experience with the condition, and the impact of their perinatal depression on their relationships with partners, infants, and others. A further sub-objective was to understand fathers’ help-seeking behaviors and support experiences in the perinatal period.

Review questions

How do fathers experience depression during the perinatal period?

Further sub-questions are also considered to meet the additional objectives:

  • i) How do men recognize and understand perinatal depression?
  • ii) What emotions do fathers experience with perinatal depression?
  • iii) What is the influence of perinatal depression on fathers’ relationships with partners, infants, and others?
  • iv) What are fathers’ help-seeking behaviors and support experiences in the perinatal period?

Inclusion criteria

Participants

This review considered studies that included fathers aged 18 years or over with born biological children (ie, conceived together with their partner) or whose partner was pregnant with their child, and who had experienced depression/postnatal depression/depressive symptoms during the perinatal period. Adoptive fathers or stepfathers (of children not conceived with a partner or where surrogacy has been used) or fathers under the age of 18 years were excluded. Fathers with a diagnosis of severe/enduring mental illness, such as bipolar disorder, schizophrenia, or personality disorder, were also excluded.

Inclusion criteria aimed to ensure results included the majority of fathers to enable generalizability in the findings. Including only biological fathers is justified, first because father distress is acknowledged to be highest during pregnancy,5 but also because adoptive parents or step-parents may experience different family dynamics, such as post-adoptive depression or difficulty bonding with a non-biological child. Age limits were selected because research into younger fathers is under-represented.29 Fathers under 18 years are also likely to experience different dynamics (eg, not being employed due to being in full-time education) compared to fathers over 18 years, so again, this does not represent the majority of fathers. Severe mental illness also increases the likelihood that depression is not associated with the perinatal period, so this was also excluded.

Phenomenon of interest

This review considered studies that explored depression in men, including wider mental distress terms used in databases and male-specific symptoms as outlined in literature, such as anger,22 as experienced by men during the perinatal period (ie, from pregnancy to 12 months’ postpartum4). Studies where the focus was trauma or perinatal loss were excluded due to grief being a cause of distress. A severely unwell partner or child, including the mother being admitted to a perinatal unit, were also exclusion criteria. Studies of clinical interventions, including for paternal perinatal depression, were excluded. The rationale for this was to retain a focus on fathers’ lived experiences of perinatal depression, their emotions, relationships, and help-seeking behaviors (as reflected in the research objectives), rather than the effects of an intervention (which could be short term or where findings could be less focused on the experience of depression).

Context

This review considered studies that focused on the perinatal period. Geographical location of the research was limited to country members of the Organisation for Economic Co-operation and Development (OECD), which works internationally with economic and social policy.30 Member countries are Australia, Austria, Belgium, Canada, Chile, Colombia, Costa Rica, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Korea, Latvia, Lithuania, Luxembourg, Mexico, Netherlands, New Zealand, Norway, Poland, Portugal, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Turkey, the United Kingdom, and the United States. The rationale for selecting OECD countries was because member countries share some homogeneity in economic and social outlook, which likely translates into common population lived experiences (eg, experiences of health care services, income, employment, and culture).

Types of studies

This review considered interpretive studies that drew on the experiences of fathers with depression including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, and feminist research.

Methods

This systematic review was conducted in accordance with JBI methodology for systematic reviews of qualitative evidence.26 This review followed an a priori protocol, which was registered with PROSPERO and is publicly available online (CRD42021245894).31 This was to ensure transparency of reporting at each stage of the review process.

To avoid reinterpreting empirical findings and imposing researcher bias, a meta-aggregative approach was used to synthesize and present findings, consistent with the JBI approach.26 Further studies on paternal perinatal depression have been completed since 2019, justifying a new systematic review in the area.

Search strategy

The search strategy aimed to locate both published and unpublished studies about paternal perinatal depression. A three-step search strategy was utilized. First, an initial limited search of MEDLINE (EBSCO) and CINAHL (EBSCO) was undertaken based on the PICO mnemonic keywords, index terms, and common words in titles and abstracts. Second, these words, alongside other words related to the objectives (eg, “emotion”) and introduction (eg, “anger”), were constructed into a final search strategy. This was initially run through MEDLINE to ensure relevancy of results, before being modified for each database. All searches took place on August 9, 2021. The full search strategies are provided in Appendix I. Third, reference lists of included studies were screened for additional studies relevant to the inclusion criteria, but which had not already been produced by the database search.

Only studies published in English were included due to lack of resources for translation. The search included studies dated since 2000, because there are few papers prior to this date focused on paternal perinatal depression. This is reflected in recent reviews, where papers were dated from 200217 and 2003 onwards.32

The databases searched included MEDLINE (EBSCO), CINAHL (EBSCO), PsycINFO (EBSCO), Scopus (Elsevier), and ProQuest Sociology. Sources of unpublished studies and gray literature were searched and included ProQuest Dissertations and Theses Global and OpenGrey.

Study selection

Following the search, all identified citations were collated and uploaded into EndNote Web (Clarivate Analytics, PA, USA) and duplicates removed. Following a pilot test, titles and abstracts were screened by two independent reviewers (CD and VS/JL) for assessment against the inclusion criteria for the review. Potentially relevant studies were retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment, and Review of Information33 (JBI SUMARI, JBI, Adelaide, Australia). Full-text studies that did not meet the inclusion criteria were excluded and reasons for their exclusion are provided in Appendix II. Any disagreements that arose between the reviewers were resolved through discussion or with a third reviewer (JL).

Assessment of methodological quality

Eligible studies were critically appraised by two independent reviewers (CD and VS) for methodological quality using the standard JBI critical appraisal checklist for qualitative research.34 By appraising and scoring its “design, conduct and analysis,”34(p.2) the credibility and dependability of each study was assessed. No modifications were made to the checklist. Authors of papers were contacted to request missing or additional data for clarification, where required. All studies, regardless of the results of their methodological quality as scored in the critical appraisal tool,34 were considered for data extraction and synthesis (where possible). The justification for this was the qualitative review design, whereby participant quotes from the primary studies would be pulled into categories and synthesized themes. However, this required author interpretation of data on a sub-theme level (ie, interpretation of concepts within identified themes). Descriptive data described by authors as interpretative would have been considered poor quality, but no such studies were excluded based on quality.

Data extraction

Data were extracted from studies included in the review by two independent reviewers (CD and VS) using the standardized JBI data extraction tool. The data extracted included specific details about the participants, context, culture, geographical location, study methods, and the phenomenon of interest relevant to the review objective (see Appendix III). Findings were extracted as embedded interpretations from authors on a sub-theme level. For instance, in one study, a theme and sub-theme were “Help seeking for mental health concerns in the perinatal period” (theme) and “Stigma” (sub-theme).35(p.317) Embedded within the sub-themes was the verbatim interpretation of “stigma around seeking help as being driven by a reluctance to feel or be seen as weak or vulnerable.”35(p.317) These findings were then assessed as unequivocal (U), credible (C), or not supported (NS). The balance of credible (54) and unequivocal (55) findings was similar. There were no unsupported findings. Authors of papers were contacted to request missing or additional data, where required. In the case of two online studies, where identities of fathers could not be confirmed, it was assumed that participants met the eligibility criteria both in relation to age and that they were biological fathers.36,37

Data synthesis

Qualitative research findings were, where possible, pooled using JBI SUMARI with the meta-aggregation approach.26 This involved the aggregation or synthesis of findings to generate a set of statements that represented that aggregation, through assembling the findings and categorizing these findings based on similarity in meaning. These categories were then subjected to a synthesis to produce a single comprehensive set of synthesized findings that could be used as a basis for evidence-based practice. Where textual pooling was not possible, the findings were presented in narrative form. Only unequivocal and credible findings were included in the synthesis.

Assessing confidence in the findings

The final synthesized findings were graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.38

Results

Study inclusion

Overall, 923 papers were identified and exported to EndNote Web and 232 duplicates removed. Of the 691 papers screened by title/abstract, 54 were retrieved for full-text review. Of these, 23 focused on an ineligible phenomenon of interest, 10 had an ineligible population, nine used an ineligible method, two had ineligible context, and one was not available. Nine studies were discovered through searching reference lists, but none of these were eligible. Nine studies were included in the review. See the full Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram in Figure 1.39

F1
Figure 1:
Search results and study selection and inclusion process39

Methodological quality

All nine studies were included in the review following appraisal using the JBI critical appraisal tool34 (see Table 1). Two studies had the highest possible score of 10.29,40 Three studies scored 9/10,36,41,42 one scored 8/10,43 and three scored 7/10.35,37,44 Two reviewers agreed that each study had congruency between the methodology and research question, data collection methods, analysis of data, and interpretation of results. It was unclear in three of the studies35,37,44 if the philosophical perspective was congruent with the research methods, though it is possible authors expected this would be assumed and/or may have been due to word restrictions in journal guidelines. Four of the papers35,37,43,44 did not have a statement positioning the researcher theoretically, but discussion between CD and VS concluded the dependability was sufficient for inclusion. All the study conclusions were considered to flow from the analysis, and the reviewers agreed to include each paper in the review.

Table 1 - Critical appraisal of eligible studies
Study Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10
Allen 41 Y Y Y Y Y Y U Y Y Y
Baldwin et al. 29 Y Y Y Y Y Y Y Y Y Y
Beestin et al. 40 Y Y Y Y Y Y Y Y Y Y
Darwin et al. 42 Y Y Y Y Y Y U Y Y Y
Eddy et al. 36 Y Y Y Y Y Y Y Y N Y
Mayers et al. 37 U Y Y Y Y N Y U Y Y
Pedersen et al. 44 U Y Y Y Y N N Y Y Y
Schuppan et al. 35 U Y Y Y Y N Y U Y Y
Webster 43 Y Y Y Y Y N Y U Y Y
Total % 67 100 100 100 100 56 67 67 89 100
Y, yes; N, no; U, unclear.
JBI Critical Appraisal Checklist for Qualitative Research
Q1 = Is there congruity between the stated philosophical perspective and the research methodology?
Q2 = Is there congruity between the research methodology and the research question or objectives?
Q3 = Is there congruity between the research methodology and the methods used to collect data?
Q4 = Is there congruity between the research methodology and the representation and analysis of data?
Q5 = Is there congruity between the research methodology and the interpretation of results?
Q6 = Is there a statement locating the researcher culturally or theoretically?
Q7 = Is the influence of the researcher on the research, and vice-versa, addressed?
Q8 = Are participants, and their voices, adequately represented?
Q9 = Is the research ethical according to current criteria or, for recent studies, is there evidence of ethical approval by an appropriate body?
Q10 = Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?

Characteristics of included studies

All studies included in the review were qualitative, dated between 2002 and 2021. Five were conducted in the UK,29,37,40,42,43 two in the United States,36,41 one in Australia,35 and one in Denmark44 (see Appendix III), all of which are OECD countries. Methods included phenomenology,36,41,43 interpretative phenomenological analysis,40,44 thematic analysis,35,37,42,43 framework analysis,29 and content analysis.36 Seven used interviews as their data collection method,29,35,40-44 one examined online narratives,36 and another used a survey.37 All participants (N = 138) were fathers of babies or young children. At least 49 were first-time fathers, with studies identifying 2,41 5,35 7,44 14,42 and 2129 first-time fathers. Four studies did not report the number of first-time fathers.36,37,40,43 Only two studies focused specifically on paternal perinatal depression.36,44 Three papers focused on father mental health in general,29,35,42 and four studies focused on fathers within the context of the impact of maternal mental illness on the father.37,40,41,43

Review findings

Through repeated reading of the studies, and agreement by two researchers (CD and VS), 109 findings (55 unequivocal and 54 credible) were extracted and aggregated into 22 categories, which were subsequently aggregated into six synthesized findings based on similarity of meaning around the phenomena of interest and context (Table 2). Final findings, illustrations, and assigned credibility levels are presented in Appendix IV.

Table 2 - Synthesized finding 1
Findings Category Synthesized finding
‘Stress’ rather than mental health [C] 1. Emotions experienced by fathers in the perinatal period are distressing but are not recognized or understood as depression. 1. Mental health literacy around paternal perinatal depression is poor among men. Fathers do not recognize or understand their distress as (postnatal) depression, but rather as stress, powerlessness, negative emotions, feeling trapped, and shame. The difference between perceptions and reality of fatherhood, and the difficulties that arise from this, cause them to feel inadequate.
Minimising feelings and becoming more irritable with their partner were common reactions to stress, particularly in the early postnatal period [C]
Feeling powerless [U]
Feelings of being overwhelmed that were difficult to express [U]
Emotions of confusion, exhaustion, helplessness, feeling alone, and trapped [C]
Heightened physical changes and emotional responses [U]
A feeling of neglect and powerlessness [C]
Trapped and unable to escape from the reality of fatherhood [U];
Felt very ashamed [U]
All the fathers recognized different changes in their mood and behavior but many of them did not perceive these changes as signs of depression [C]
Emotive feelings [C]
General feeling [C]
Fathers’ great expectations were later replaced by a very different reality of fatherhood [U] 2. Reality of the situation is different to perceived expectations and often only realized after the baby is born.
Mundane manifestation [U]
Parenting only became ‘real’ once they were ‘doing’ it [C]
For many men their baby did not seem ‘real’ during their partner's pregnancy [U]
Unmet expectations often left them with a feeling of being inadequate [C] 3. Fathers feel inadequate when their expectations do not match their actual reality of fatherhood.
Expectations of fatherhood were replaced by feelings of unfulfillment and inadequacy [C]
The fathers expressed feelings of inadequacy around not being able to “fix” things for their significant other [U]
U, unequivocal; C, credible

Regarding the ConQual score,38 the studies in each synthesized finding scored 4 or 5 for dependability, thus the score remained unchanged. However, the score for credibility was downgraded one level due to the combination of credible and unequivocal findings. Therefore, the ConQual score for each synthesized finding was “moderate.”

The synthesized findings offer a rich understanding of fathers’ experiences of depression in the perinatal period. These synthesized findings answer the overall research question by describing how fathers experience depression in the perinatal period, but also the sub-objectives, including how they experience emotion; the impact on their relationships with their partner, child, and others; and their help-seeking behaviors.

Synthesized finding 1: Mental health literacy around paternal perinatal depression is poor among men

Fathers do not recognize or understand their distress as (postnatal) depression, but rather as stress, powerlessness, negative emotions, feeling trapped, and shame. The difference between perceptions and realities of fatherhood, and the difficulties that arise from this, cause them to feel inadequate.

Nineteen findings divided into three categories produced this synthesized finding (see Table 2). The most pertinent observation from the studies was that emotions experienced by fathers in the perinatal period are distressing but are not always recognized or understood as depression (category 1). Fathers did not explicitly consider themselves to be suffering from depression, nor did they commonly verbalize that they were experiencing depression, despite many of the terms they used to describe their feelings being consistent with depression. Rather, they described “emotive feelings”43(p.392) such as “confusion, exhaustion, helplessness, feeling alone, and trapped.”36(p.1008) Some of these feelings arose from the difficulties of parenting, where a participant acknowledged his depression in relation to mood and irritability:

I’m always exhausted, even the rare nights where I get 7 or 8 hours of (albeit interrupted because of baby) sleep. I’m very frequently depressed, in a sour mood or very irritable.29(p.1008)

This was supported in reference to “heightened physical changes and emotional responses”37(p.6):

I was scared. I could not sleep. My memory lapsed and I cried too often37(p.6)

Similar emotions identified through findings included both a feeling of “neglect and powerlessness,”44(p.5) which one participant contextualized as being unimportant:

I feel totally unimportant […] what is it, that my role is then? […] I hoped […] that we would be equal.44(p.5)

Fathers also referred to a need to control the situation:

So where there's something like that, like, fatherhood and things that I can’t plan and things like that, I find it quite hard to digest. If there's something I can control, a plan and put in a Gantt chart, great, I can deal with that.42(p.8)

This seemed to be in relation to “feeling trapped and unable to escape from the reality of fatherhood,”44(p.5) where participants vividly verbalized the feelings arising from this as including hate, irritation, and anxiety:

I didn’t feel frustrated, I felt […] a hate, almost […] my life was so good before I met [my wife]. Why in hell did I agree to this? […] This child [went] from being something fantastic to be a drag, a major source of irritation in my everyday life.44(p.5)

Fathers were also ashamed of their emotions:

When you have these thoughts inside your head, you become completely broken inside. Because it is so shameful.44(p.5)

There were, therefore, difficult feelings experienced by fathers during the perinatal period, which may be linked to an interpretation of the “general feeling”43(p.392) by fathers that:

It is something that people tend to keep to themselves and don’t want to admit to. If they do admit, then there are no resources there to actually help you.43(p392)

However, despite verbalizing these emotions, fathers were aware of changes to their mental health, highlighted by the finding, “All the fathers recognized different changes in their mood and behavior, but many of them did not perceive these changes as signs of depression.”44(p.6) One participant stated:

You know that something is wrong, but you don’t know what it is.44(p.6)

This demonstrates that, in addition to not always considering depression in the perinatal period as a condition they were experiencing, fathers also exhibited poor mental health literacy around their perinatal depression. This is highlighted by men referring to “‘Stress’ rather than mental health”42(p.5):

I think for me it's just–the never having any time to relax, it's just not possible. I’ve got a stressful job then I come home and I tend to get…the tired, stressed baby…I think the stress for me is just the non-stopness of it.42(p.5)

In the perinatal period specifically, feeling this “stress” had consequences for their behavior. Fathers reacted by “minimizing feelings and becoming more irritable with their partner,”42(p.5) which is illustrated by a father claiming:

I tend to do the typical man thing of hiding it until I can do so no longer…I’m not the sort to wail and shout and whatever…I probably just get grumpy and a bit snappy about stuff. That's pretty much it really.42(p.5)

Fathers also experienced “feelings of being overwhelmed that were difficult to express,”36(p.1008) but that were consistent with depression:

I was so ready to be a dad but all I can think about is how miserable I am.36(p.1008)

I have the feeling that I’m constantly on the edge of bursting into tears. My work, which I used to be able to cope with well, seems extremely stressful now. I’m easily irritable, I can’t stand my 7-month baby's cry over more than a few minutes without becoming angry.36(p.1008)

For many fathers, the notion that their parenthood did not feel real until it happened was linked to these emotions. The second category identifies that the reality of the situation is different to perceived expectations, which is often only realized after the baby is born (category 2). For fathers, this was specifically observed during pregnancy, highlighting that this is a unique period for men in terms of their transition to fatherhood and mental health. One finding suggests that, “For many men, their baby did not seem ‘real’ during their partner's pregnancy.”29(p.5) This is illustrated by an unequivocal quote:

Even though the baby was there, you can see the bump, you can see, you know, the baby moving around inside, to me, it wasn’t there. Yeah, it wasn’t real. It's only until she was born.29(p.5)

This statement was further reinforced by the finding, “Parenting only became ‘real’ once they were ‘doing’ it,”42(p.8) affirming pregnancy as a time of “unreality” for fathers-to-be, but one that they react to pragmatically:

As we approached due date, I was getting less sleep due to worrying about it, but once it was there, we just got on with it.42(p.8)

The difference between reality and expectations meant that “Fathers’ great expectations were later replaced by a very different reality of fatherhood,”44(p.4) indicating a perceived incongruence between what is meant to be and what is. Three men commented on this in one study:

It's a radical change that you just can’t imagine.44(p.4)

Nobody tells you how hard it really is, and thank God for that, because then there wouldn’t be born any more children into this world.44(p.4)

All of these false fantasies, which are set up by other parents, society, everything. It's not what you think.44(p.4)

Consistent with these bleak observations of reality, the perinatal period was also perceived as a “mundane manifestation,”40(p.724) a further negative description of the situation that one father described:

I have been really fed up and I just don’t want anyone around me […] I just don’t wanna be around anyone and the kids will be like, saying like ‘daddy's in a really bad mood, what's wrong with you daddy?’ and I’m mumbling and being grumpy and whatever, but it's a case of it's just too much.40(p.725)

The third category represents fathers feeling inadequate when their expectations do not match their actual reality of fatherhood (category 3). Both their experienced negative emotions and the feeling that the situation was not “real” in pregnancy had a deep impact on fathers. Fathers’ reactions to their expectations not matching reality were also aligned with their negative emotions and left them with a “feeling of being inadequate.”44(p.4) Two fathers in one study related this to feeling they were lacking personal skills in some way:

There are a few things a father needs to handle […] He needs to have a job, and he needs to have a garage […] and I didn’t have any of those things.44(p.4)

I felt like everything had to be perfect. [I wanted] my family to thrive, and in the end, it backfired.44(p.4)

Particularly in the context of the mother struggling with depression, fathers struggled “around not being able to ‘fix’ things.”41(p.48) One participant stated:

Well like I said, I didn’t really have a huge instinct as to how to care for a newborn baby or how to parent, I never spent time with a baby so when my wife didn’t want to do it anymore or wasn’t sure what to do it made things more helpless. You know being a guy you want to fix it and if you can’t fix it and you feel helpless.41(p.49)

These findings also linked to the “powerless” emotion felt in the first category, generating a similar meaning that contributed to this synthesized finding. Another negative emotion linked to inadequacy was where “Expectations of fatherhood were replaced by feelings of unfulfillment and inadequacy.”44(p.4) In contextualizing the reality between his expectations, one father stated:

[…] the strength as I imagined. The magic, if you can call it that, I never felt it.44(p.4)

Synthesized finding 2: Relationships are experienced as both comforting and distressing in the perinatal period

Men experience complex reactions to the new relationships with their partner and child in the perinatal period. This includes feeling distant from their partner and unable to bond with the child. Transitioning to new relationships in the household triggers resentment and strain in fathers, and increases feelings of isolation as they struggle to cope. However, fathers still prioritize the partner and child's well-being in their help-seeking.

Here, 19 findings comprising 3 categories were aggregated (see Table 3). Overwhelmingly, when men become fathers, the studies suggest that complex relationships with the partner and child are related to both a father's mental health and his help-seeking.

Table 3 - Synthesized finding 2
Findings Category Synthesized finding
Some of the fathers internalized their partner's symptoms and felt they were to blame [U] 4. Fathers experience less closeness with partners, but they are still their main source of support. 2. Relationships are experienced as both comforting and distressing in the perinatal period. Men experience complex reactions to the new relationships with their partner and child in the perinatal period. This includes feeling distant from their partner and unable to bond with the child. Transitioning to new relationships in the household triggers resentment and strain in fathers, and increases feelings of isolation as they struggle to cope. However, fathers still prioritize the partner and child's well-being in their help-seeking.
They want their partners to understand that they are also afraid and that even though they do things differently, it doesn’t mean that it's wrong [C]
Changes they noticed in their relationship with their partner [U]
Disclosures about the psychological and emotional challenges men had experienced were prompted by discussions between partners [U]
The loss of a previous ‘closeness’ [U]
Struggling to understand their partner's perspectives, both physical and emotional, which could be a source of strain in the relationship [U]
Fathers felt neglected by their wives [C]
Negative impact on their relationship with their partner [C]
Their partner or other family members could have had a great influence on the father's help-seeking behaviour [U]
Unable to seek help when there were others, particularly their partners, who were having a more difficult time [C]
Visible impact of their mental state on their partner or child would be a strong prompt to seek help [U] 5. The partner and child well-being remain a priority to fathers above their own.
Feared that speaking openly about suicidal thoughts and thoughts about harming their own child would be used against them [C]
Some fathers also expected an instant bond with their baby and when this didn’t happen they found the experience quite challenging [C] 6. Fathers experience distress, lack of bonding, and resentment towards their babies.
Men's coping capacity was often strengthened through their positive and rewarding experiences of fatherhood; something that grew with the child's development and his/her increasing ability to interact [C]
Resented their baby's constant needs and attention [U]
Not enough information (and reassurance) on father-child bonding activities [U]
Perceived inability to comfort and meet the basic needs of their child [C]
Strong emotional distress when they needed to comfort their crying child [U]
Painful thoughts of suicide and harming their own child [C]
U, unequivocal; C, credible

The first category identifies that fathers experience less closeness with partners, but partners are still their main source of support (category 4). Strikingly, “Changes they noticed in their relationship with their partner”29(p.7) were verbalized, and this referred to both arguments and decreases in sexual activity. Two participants in one study on father mental health during transition to fatherhood disclosed:

I probably argue a bit more and that's probably just due to my tiredness.29(p.7)

What possibly has suffered is that in some way, sexually, we haven’t been as intimate.29(p.7)

These changes included a “Negative impact on their relationship with their partner”37(p.6) and were significant in explaining father distress, highlighted by a participant who wrote:

Things became very difficult and pushed us apart.37(p.7)

Such “pushing apart” was consistent with fathers perceiving the “loss of a previous ‘closeness’.”42(p.7) One father described this in reference to the mother and baby being a unit, with him being separate:

[For women] it becomes about me and bump, and then me and baby. Whereas fathers, it's about them, you know, them two over there and me. You feel part of that unit but nonetheless, you’re always separated slightly…that's just how it is.42(p.9)

Aligned to this separation was that men also “felt neglected by their wives,”36(p.1009) which was damaging to the relationship:

I blamed both her [wife] and my son for my feelings of loss and insignificance. I took on every parental responsibility with sucked up reluctance on the outside and contempt on the inside. My wife seemed to consider me selfish and irresponsible. Even when the bickering ended, the wounds never healed. Our marriage took a fatal hit.36(p.1009)

Despite this distance, partners remained a key source of support for fathers. One finding identified that “Their partner or other family members could have had a great influence on the father's help-seeking behaviour.”44(p.7) Men, particularly, verbalized that they needed their partners to initiate the conversation around their depression; this was highlighted by two participants:

Maybe the mothers need to be better at saying something […] because, we don’t say anything in the beginning. It takes a long time before we say anything.”44(p.7)

I don’t think [fathers] know that they have [PPD]. I think someone needs to grab [the fathers] and say, ‘you need help’ […] just like [my wife] said to me.44(p.7)

Furthermore, partners were pivotal in men recognizing their depression, highlighted in the finding: “Disclosures about the psychological and emotional challenges men had experienced were prompted by discussions between partners.”42(p.6) In response to a partner noticing a man's withdrawal, he directly replied:

Yes, I could feel myself withdraw, so I wouldn’t communicate as much and I would get snappy when sometimes I wouldn’t do.42(p.6)

This mirroring of a partner's voice was also consistent with their reactions to a partner's depressive symptoms, where “fathers internalized their partner's symptoms and felt they were to blame.”41(p.46) This is highlighted in the following quote:

When my wife was very down and depressed and especially when she was angry, it kind of came over on me and then made some frustrations in our relationship. We seem to argue a lot more because of it. I would notice when we were around each other and she was down like that, I would get more down. Or, when she was more irritated, I would be more irritated.41(p.46)

It is, therefore, clear that each partner's needs, and acknowledgments of these needs, affect men's experiences of their relationships. Another example was the difficulties fathers had understanding their partner's physical and emotional needs, which could be “a source of strain in the relationship”42(p.7):

I struggled at times because whilst I could see of the physical effects on [partner], I couldn’t understand the emotional and mental effects it was having on her, so I struggled with that, and I probably did become a bit more snappy, definitely low mood at times and struggling to sort of sleep properly, and you have a lot to think about.42(p.7)

To negate this strain and loss of closeness, fathers wanted mothers to understand their fears, because these caused fathers to withdraw from their relationships:

I think men have received a lot more messages in terms of what not to do than what to do. I guess just some societal validation for being a good dad, they’re just isn’t much of it. You never hear anything like you know he's a really good dad, you just don’t hear that much.41(p.66)

This withdrawal was also represented in a further finding, where despite partners being a support for fathers, their needs would overrule their help-seeking where they are “Unable to seek help when there were others, particularly their partners, who were having a more difficult time.”35(p.320)

Thus, despite their acknowledged distress in the perinatal period, and the documented changes in relationships with their partner, partner and child well-being remain a priority to fathers above their own (category 5). This was confirmed by the unequivocal statement that in the event that their mental health was affected, their partner or child would be a strong prompt to seek help:

I think if at any stage I recognize in myself that I was yea putting myself ahead of those two then that to me wouldn’t that wouldn’t sit well with me [yea] internally not to say it's not right but then that's when I’d be looking for services to help try and combat that.35(p.318)

However, despite fathers wanting to protect their families from their mental health problems, they were simultaneously fearful of verbalizing their true feelings because this may result in professionals initiating a safeguarding process. They “Feared that speaking openly about suicidal thoughts and thoughts about harming their own child would be used against them,”44(p.7) and this was disclosed particularly in reference to the health visitor:

[The health visitor] is a public authority […] She has to go forward with the [information], if it is [necessary] […] If I say too much about something, will they take [my son]?44(p.7)

This highlights another conflict in fathers’ mental states around the well-being of their children and themselves. The third category in this synthesized finding indicates that fathers experience distress, lack of bonding, and resentment towards their babies (category 6). There was a common acknowledgment that fathers “expected an instant bond with their baby and when this didn’t happen they found the experience quite challenging.”29(p.6) This was evidenced by a father verbalizing that the child did not know him:

… particularly in the first week when the baby doesn’t recognize you, of just not feeling like they – you can make them feel better. I would say that's probably a challenge.29(p.7)

Fathers felt there was “Not enough information (and reassurance) on father-child bonding activities,”37(p.6) a finding that was illustrated unequivocally. Furthermore, in addition to not always bonding instantly, fathers also felt that they did not know how to comfort their child, summarized in the finding “Perceived inability to comfort and meet the basic needs of their child”44(p.4):

When [my daughter] became upset […] I felt the frustrations building up inside, and then I gave up […] I simply couldn’t do it […] and then I felt guilty […] I’m not even good at that.44(p.4-5)

This was both distressing and also reinforced feelings of guilt. Linked to this frustration was the “strong emotional distress”44(p.5) fathers experience when their babies cry:

It's when he cries. I simply can’t have it.44(p.5)

It is during the night […] he just screams. Imagine a child who just screams, and you cannot do anything. You don’t know what to do about it.44(p.5)

This highlights guilt and distress arising directly from the baby's cry. Perhaps unsurprisingly, men “Resented their baby's constant needs and attention,”36(p.1008) although it is important to note that this was mainly disclosed in a study that analyzed anonymous online forums36; however, it was evidenced repeatedly:

Baby cries can unearth some darkness in me, I’ve found.36(p.1008)

When I’m personally caring for our son I’m overwhelmed with hate. I hate this baby. I thought my dislike for him would go away and I’d start to bond but it's gotten worse. I hate him. I hate his crying, his needs, his endless discontent. I’m suppressing violent thoughts of ending his life and ending my own.36(p.1008-9)

… angrily typed into google, “I hate my baby.”36(p.1009)

In some cases, highlighting resentment and lack of bonding, fathers experienced “Painful thoughts of suicide and harming their own child.”44(p.5) One participant described his thoughts vividly:

I was cooking in the kitchen and I thought […] I wonder what would happen if I cut [my son's] throat.44(p.5)

One positive finding was that fathers’ relationships with their children improved over time once the child became more interactive: “Men's coping capacity was often strengthened through their positive and rewarding experiences of fatherhood; something that grew with the child's development and his/her increasing ability to interact.”42(p.9):

I mean you cope through him as well, as he gets older. I mean just smiling to himself and being able to come back and he recognizes your face, that kind of stuff is a huge coping strategy.42(p.9)

In summary, this synthesized finding suggests that men experience complex reactions to the new relationships with their partner and child in the perinatal period. This includes feeling distant from their partner and unable to bond with the child. Transitioning to new relationships in the household triggers resentment and strain in the father, and increases feelings of isolation as he struggles to cope. However, fathers still prioritize the partner and child's well-being in their help-seeking.

Synthesized finding 3: Fathers in the perinatal period do experience depression, but this is avoided, normalized, or hidden

Depressed men experience cognitive changes as they become fathers. They become withdrawn as they start to feel isolated and unsupported. They cope with this by avoiding emotions and detaching, which impacts on their parenting, and they attempt to normalize their distress as a natural aspect of being a father.

Sixteen findings produced three categories that contributed to this synthesized finding (Table 4), which identifies that depression is likely experienced by many fathers, but the way in which they cope is to avoid, normalize, or hide their feelings. The first category found that men feel progressively more isolated across the perinatal journey and retreat into themselves to cope (category 7). An important finding was fathers’ “need to cope alone”29(p.7) in their fatherhood experience:

I tend to keep it in myself so, you know, I battle it myself.29(p.7)

Table 4 - Synthesized finding 3
Findings Category Synthesized finding
The need to cope alone [U] 7. Men feel progressively more isolated across the perinatal journey and retreat into themselves to cope. 3. Fathers in the perinatal period do experience depression, but this is avoided, normalized, or hidden. Depressed men experience cognitive changes as they become fathers. They become withdrawn as they start to feel isolated and unsupported. They cope with this by avoiding emotions and detaching, which impacts on their parenting, and they attempt to normalize their distress as a natural aspect of being a father.
Not asked about their mental health [C]
An unshared parenting load rendered fathering an unexpectedly solitary experience [C]
Taking a self-reliant and stoical attitude when deemed necessary [U]
Feelings of rejection or being ‘pushed out’ by the closeness between their baby and partner [C]
Not receiving information from doctors or therapists [U]
A sense of feeling lost or forgotten during this time of their lives [U]
Lack of support from healthcare professionals led to fathers experiencing feelings of isolation and confusion [C]
Help-seeking as an issue of personal responsibility [U]
Feeling of being a spare part [C]
Becoming preoccupied by the difficulties within the adult relationship meant that some men felt they were psychologically and physically absent as fathers [C] 8. Men detach and avoid their emotions in the perinatal period, which can result in withdrawal from their children and a reluctance to seek support.
Unlikely to seek help out of a desire to avoid difficult feelings or a sense it was not the done thing [U]
Expectations as an explanation for their own depression [C] 9. As their distress manifests, men seek to normalize and legitimize their difficult feelings.
Tried no normalise their emotions [U]
Underrate their symptoms when feeling uncomfortable [C]
Questioning the legitimacy of their own mental health needs [C]
U, unequivocal; C, credible

Despite trying to cope, however, fathers experience “Feelings of rejection or being ‘pushed out’ by the closeness between their baby and partner.”42(p.9) Isolation was experienced internally by fathers in three ways. The first was by “Taking a self-reliant and stoical attitude when deemed necessary,”42(p.9) highlighted by two participants:

I’d just get on with it. I would just deal with it myself. That's what I’ve always done. I think it tends to be a male reaction for most people.42(p.9)

And I think generally, that's my approach. It's just a case of head down, battle on through.42(p.9)

The second part of coping alone was where men were “feeling lost or forgotten during this time of their lives,”36(p.1009) where a participant referred to men's experiences of secret struggle:

Many men I’ve spoken to share a similar story of struggling with depression when their children were first born, but they do so secretly, quietly, away from the dinner table. They understand that there's no truly acceptable place or context for men to publicly reveal being challenged.36(p.1009)

The third way isolation was represented was through “Feeling of being a spare part,”35(p,320) though one father contextualized this through not feeling included in appointments:

Obviously partners can attend to all your prenatal classes and that sort of stuff but generally […] generally speaking […] most blokes are just like oh yea they sort of shrug it off and they don’t well they do listen but they don’t ask questions because they feel it's not really their place.35(p.320)

Therefore, isolation was also experienced externally, where men identified they were “Not asked about their mental health”29(p.8):

… no one really asks you how the father is doing, it's all about the baby and the mum. So, yeah, it's just a foreign concept, I think.29(p.9)

They also experienced “lack of support from healthcare professionals,”37(p.6) which one father related directly to his experience of midwifery services:

My wellbeing was of little interest to midwifes, health visitors … [I] had not given birth so had no cause for sympathy. A leaflet for my wife and a page for the fathers to read which wasn’t enough.37(p.6)

When parenting fell to the father because of depression in the mother, fathers found this isolating, which was represented by the finding an “unshared parenting load rendered fathering an unexpectedly solitary experience,”40(p.723) highlighting maternal depression as a risk factor for father isolation. They also felt “lost and forgotten.”36(p.1009)

Hiding struggles alongside their progressive isolation intersected with “Not receiving information from doctors or therapists,”36(p.1007)which related to late identification of the father's depression:

None of our reading and none of the medical professionals we talked to ever mentioned anything significant about fathers getting PPD. By the time I realized I had depression, our family had nearly broken apart.36(p.1007)

Perhaps linked to feelings of isolation and poor acknowledgment of their depression by health professionals, fathers viewed “Help-seeking as a matter of personal responsibility,”35(p.315) a concept raised in reference to screening for depression. Fathers verbalized that it was up to them to take initiative:

It certainly is up to the individual to do that.35(p.315)

The effects of this profound isolation, based on their feelings, attitudes, and experiences led to the second category. Another form of coping was to detach and avoid their emotions in the perinatal period, which can result in withdrawal from the child and reluctance to seek support (category 8). Fathers’ isolation had consequences for their relationship to the child, where “Becoming preoccupied by the difficulties within the adult relationship meant that some men felt they were psychologically and physically absent as fathers”40(p.724):

… it was his wife's emotional rejection of him, rather than her absence from mothering, which preoccupied him, leading to “darker” times and “switching off my feelings” […] to make like your own, kind of like your own postnatal depression pills.40(p.724)

In addition, men would not seek help “out of a desire to avoid difficult feelings or a sense that it was not the done thing”35(p.318):

… men talk it's not normally expressing things that are that are difficult in their lives and how they they work through that particularly [laughing] which particularly in in their marriages is is not it's not popular to […] yea express things that are hard.35(p.318)

Adding to their isolation and avoidance, as their distress manifests, men seek to normalize and legitimize their difficult feelings (category 9). For instance, they viewed their “Expectations as an explanation for their own depression.”44(p.4)

Specifically, it was identified that fathers “Tried to normalise their emotions.”44(p.6) This was a particularly pertinent finding to this review, since participant illustrations are directly related to perinatal depression:

I kept saying to myself that [my feelings] were normal […] Somehow, [I] kept challenging the narrative [regarding PPD].44(p.6)

At that time, I did not think “I have post-partum depression”. I just thought “This is normal”, because it is so damn hard.44(p.6)

It was also observed that fathers “underrate their symptoms when feeling uncomfortable.”35(p.316) This was illustrated by one father:

There may be some questions oh no I better not answer that this way because that might mean this this this or [mm] you know they they’re judging me for how I’m going to be as a father and therefore […] like I’ll just not [yep] tell the truth on this.35(p.317)

One finding suggested fathers were “Questioning the legitimacy of their own mental health needs.”42(p.5) Feeling the partner's needs were more important was a key observation:

I’m always conscious that [partner]'s got it a lot worse so I just sort of get on with it.42(p.5)

Synthesized finding 4: Fathers feel judged about mental health difficulties and so are reluctant to disclose them

Men internalize social expectations around masculinity and fatherhood, and their new role causes them to feel conflicted and confused in terms of being an involved father but also seeking support. There is an overwhelming fear of judgment among fathers suffering with their mental health.

Twelve findings and three categories comprise this synthesized finding (see Table 5), which focuses on paternal perceptions around what is expected from them and their subsequent fear of judgment.

Table 5 - Synthesized finding 4
Findings Category Synthesized finding
Perceived expectations of masculinity as well as negative attitudes towards depression [U] 10. Fathers are aware of internal and external expectations around fatherhood and this influences how they behave. 4. Fathers feel judged about mental health difficulties and so are reluctant to disclose them. Men internalize social expectations around masculinity and fatherhood, and their new role causes them to feel conflicted and confused in terms of being an involved father but also seeking support. There is an overwhelming fear of judgment among fathers suffering with their mental health.
The expectations society gives to men of what they are supposed to be [U]
The reluctance of men to share their thoughts and feelings [U]
Needed to be seen to remain emotionally and mentally strong to support their partner and baby, despite coping with their own mental health [C]
Normative masculine expectations as a barrier in seeking help [U]
Need to be strong [U]
Feelings of conflict about wanting to be more involved [C] 11. Men experience conflict and confusion around being involved fathers.
Feeling conflicted about wanting or needing emotional support [U]
Confusion of what they were experiencing and although some sought information, they were usually unable to find it [C]
Changed priorities and an altered mindset [U]
Fear of being perceived negatively by work colleagues, friends and family if a mental health problem was identified [C] 12. Fathers are fearful of judgment from others when it comes to their mental health.
Fathers’ fears of judgment [U]
U, unequivocal; C, credible

Fathers are aware of internal and external expectations around fatherhood, and this influences how they behave (category 10). Masculinity was a key feature in this category and this was evidenced repeatedly. Comments represented “Perceived expectations of masculinity as well as negative attitudes towards depression”42(p.9) as an unequivocal finding:

… there's always the fear, if you open yourself up and you explain how you are feeling emotionally, like blokes will, sort of, ridicule you, don’t be so airy fairy, you know, that, sort of thing… just because blokes try and act all macho and stuff.42(p.9)

I am a depressive, I’m depressed right now, have been for a few days…I don’t think, in any stretch of the imagination, I’m the image of the stereotypical man, and yet I’m never going to be able to breakout of the, man up, get on with it thing. And I don’t know where that comes from, just it's there.42(p.9)

These expectations were related to “The reluctance of men to share their thoughts and feelings,”36(p.1007) and were almost unanimous in content:

I don’t feel I can tell my wife about these feelings. It will make me look weak or it will sound ridiculous because she is with the kids more than me.36(p.1007)

I found myself huddled in my home office, secretly and somewhat reluctantly shedding a tear in the dark.36(p.1008)

Not being able to speak with a partner was also linked to men needing “to be seen to remain emotionally and mentally strong to support their partner and baby, despite coping with their own mental health.”37(p.6) This highlighted the suggestion that men have a clear picture of how they should behave as a father, and maintaining this image was something they strove for, despite suffering. One participant described his coping retrospectively:

It was challenging supporting my partner and baby and managing with my own mental health, but I coped.37(p.6)

Mirroring this comment was another illustration:

I think that especially if they’re trying to maintain this you know strong position […] you know especially trying to support the the female […] they might not want to show any kind of weakness.35(p.318-9)

This demonstrated that fathers felt a “Need to be strong.”35(p.318) Yet, while fathers tried to maintain this, believing it was a positive thing, they experienced “Normative masculine expectations as a barrier in seeking help”44(p.7):

Men don’t consult a doctor when their toe is a little red, they consult a doctor when the toe is red, blue and black […] So, for men to admit […] ‘I have PPD. I need [anti-depressives]’. I think that […] many men would see that as a giant failure.44(p.7)

The conflicts about asking for help for paternal perinatal depression were significant in relation to how men sought support for their depression in the perinatal period. A second category contributing to this synthesized finding is fathers experience conflict and confusion around being involved fathers (category 11).

Conflict was consistent in men's narratives; for instance, during encounters with maternity care, they felt conflicted about “wanting to be more involved.”42(p.6) They also felt conflicted about needing support, which was illustrated by one participant's quote:

I’d feel like I maybe shouldn’t want to want some support, and that I should be fine and I should just get by, and actually I have so did I need it? Probably not. Would it would be nice? Yes, maybe. Would I have gone? Different question again, maybe not.42(p.11)

Therefore, fathers internalized the perceived social expectations of others, which then resulted in them feeling conflicted about seeking help for their mental health. Additionally, when they felt conflicted in terms of understanding their experience, their efforts to find information to improve the situation were unsuccessful. This was illustrated in a finding: “Confusion of what they were experiencing and although some sought information, they were usually unable to find it.”36(p.1007) In reference to literature on postnatal mental health, one participant suggested:

The book gives surprisingly minimal attention to what a postpartum husband might do to take care of his own well-being.36(p.1007)

Within this category, conflict and confusion were also linked with change. Three participants unequivocally shared their feelings and reactions regarding “Changed priorities and an altered mindset”29(p.5):

In terms of your mind set changes a bit, as well…so you start thinking differently. Now you’ve got boundaries, yeah? You can’t cross them boundaries.29(p.6)

A final category describes that fathers are fearful of judgment from others when it comes to their mental health (category 12), further emphasizing the inner turmoil some fathers experienced in relation to their mental health struggles in the perinatal period. Two findings directly linked to this category, both with similar meanings. First, fathers experienced “Fear of being perceived negatively by work colleagues, friends and family if a mental health problem was identified”29(p.9):

I guess, it's that fear of worrying about well, if you went and then seek help, how would your company see that? How would your friends and family see that? Is that something you want to disclose? … I think that sometimes can be the making or breaking point for someone where, if you do need to seek the advice, but you don’t because of other fears, it then means that you’re learning to cope with it in different ways.29(p.9)

There was also evidence of fathers’ “Fear of judgment”35(p.316):

… what are they going to what are they going to think of me if my […] you know my struggling is to get out in the open [yea] what consequences does that have [yep] you know I’m supposed to be the strong […] person [yea] particularly at this time of my life […] so I don’t want weakness to show.35(p.316)

Synthesized finding 5: Help-seeking in fathers is prevented by non-targeted support for fathers

There is a lack of specific information and support for fathers. This reinforces stigma and poor mental health literacy around perinatal depression, although screening helps men identify as having perinatal depression. Having no pathway to follow, fathers fear wasting professionals’ time and either avoid seeking help or wait until they reach crisis point, fearing being put on medication.

Meta-aggregation of 26 findings and six categories produced this comprehensive theme focusing on support (Table 6). The first category identifies an acknowledged lack of targeted individualized support for fathers in the perinatal period (category 13). Whilst support for men was raised in all studies, it was identified that the format of this help should be exclusive to the fathers’ needs. For instance, one author identified that “support groups are not something that would work well with fathers,”41(p.61) and this was based on both taking away from family time and men's discomfort in disclosing their feelings:

I would like it if it was for the father and it helped me know how to react. I would really be open to that, but like I said the last thing I want to do, is be in a room full men when I could be at home with my kids and wife.41(p.62)

In theory [a group] it's a good idea, but I think when you look at the psyche of man, they aren’t really going to sit around and talk to each other and open their feelings.41(p.62)

Table 6 - Synthesized finding 5
Findings Category Synthesized finding
In getting help, the fathers agree that support groups are not something that would work well with fathers [U] 13. There is an acknowledged lack of targeted individualized support for fathers in the perinatal period. 5. Help-seeking in fathers is prevented by non-targeted support for fathers. A lack of specific information and support is available for fathers. This reinforces stigma and poor mental health literacy around perinatal depression, although screening helps men identify as having perinatal depression. Having no pathway to follow, fathers fear wasting professionals’ time and either avoid seeking help or wait until they have reached crisis point, fearing being put on medication.
A lack of appropriate support and information for new fathers [U]
Lack of equivalent groups for fathers [C]
A preference for information that was geared towards fathers [C]
Written materials may be more acceptable to some men, offering a route to further information and support [U]
An extreme imbalance between the level of support fathers receive from healthcare professionals compared to mothers [U]
The focus should primarily be on the woman, as she carries the baby and gives birth to their child [C]
Support and protection [U]
An overwhelming sense of despair at the lack of support [C]
Existing relationships that offered ways to ‘casually explore concerns and gain reassurance’ [C]
Most fathers said they would only approach health professionals as their last port of call and the GP would be their professional of choice [C] 14. The general practitioner (family doctor) is the main preferred support, but this is a last resort because fathers fear wasting their time and view support for the mothers as the priority.
Men feared taking up health professionals’ time with their own mental health worries and avoided seeking help [C]
Men who reported having consulted their GP in relation to their mental health described more marked symptoms [U]
Conception of the perinatal healthcare services being geared towards women [C]
The fathers want the information to be explicitly from the male perspective [U] 15. In terms of support, men want a male perspective that understands the paternal experience.
Fathers want therapists who understand what the father goes through [C]
Paternal PPD as taboo [U] 16. Men view postnatal depression as affecting mothers and experience stigma around father mental health problems.
Stigma was a barrier to help seeking [C]
Stigma around seeking help as being driven by a reluctance to feel or be seen as weak or vulnerable [U]
Not knowing men could suffer from postpartum depression [U]
Believing that PPD is a gender specific condition [U]
Crisis point [C]
Screening was an important part of the help seeking process [C] 17. Screening is beneficial in encouraging some fathers to think about their symptoms and link these to depression.
Screening process as raising their awareness of their own symptomatology [U]
Feared that seeking support would be met with a psychopharmacological response [U] 18. Fathers do not want to seek support just to be prescribed medication for depression.
Negative expectations about current treatment options [U]
U, unequivocal C, credible; GP, general practitioner; PPD, postpartum depression

These findings were mirrored in other results, where a participant cited a “Lack of equivalent groups for fathers”42(p.10):

I think in some ways it would be helpful before and after to make sure that dads are prepared and that they’re coping and maybe even if it was just away from the mums for some people maybe, because I think some dads might find it a bit embarrassing to say I don’t know what I’m doing.42(p.10)

While this highlighted that groups were not the preferred method of support for men, there was “A preference for information that was geared towards fathers,”42(p.11) illustrated by men referring to the websites mothers use. Some participants positively referred to written materials:

I really enjoyed reading [the Dad's handbook]…because a lot of it was based on other people's experiences so you realise you’re not in the boat by yourself, that there are other people that have been through it and obviously a natural thing that everyone does every day.42(p.11)

Perhaps if there was some sort of dads thing, like a bounty pack which is just for dads.42(p.11)

This difference between support availability for mothers and fathers was verbalized:

Mothers have support from midwives and health visitors, but dads get nothing.37(p.6)

One study highlighted the “overwhelming sense of despair”35(p.321) men feel about there being no support available:

I didn’t really feel that I didn’t really you know come across any services that were directly offered for me.35(p.321)

However, mirroring the previous synthesized finding, fathers felt “The focus should primarily be on the woman, as she carries the baby and gives birth to their child.”37(p.6) Similarly, fathers felt responsible as a source of support and protection for their families:

You gotta be the bloke and hold the family up.35(p.318)

This category, therefore, raised an important issue of support targeted for fathers, with numerous potential barriers to success, including format (eg, group vs written), family pressures, and men's feelings about being the strong one for the family. The subsequent category focuses on where men first access support. In this review, the general practitioner (GP) was the main preferred support, but this was a last resort because fathers fear wasting their time and view support for mothers as the priority (category 14).

Fathers referred to the GP as a source of help-seeking, where the GP was their “professional of choice.”29(p.8) Participants referred to the GP in numerous studies.29,42,44 One study42 identified that the fathers who visited the GP for their mental health struggles “described more marked symptoms”42(p.6):

In the end I just couldn’t function… I wasn’t myself. I couldn’t even make simple decisions.42(p.6)

I felt so ill, I just wanted to die. I just thought this is awful.42(p.6)

However, again, men felt the professionals’ time may be better used elsewhere, indicating a lack of value on their own needs:

I feel like you really are aware – with that in mind, you really are aware that you’re taking up somebody else's time if you are to be in that position, and it's like, you know, I don’t want to bore you with my troubles.29(p.8)

In addition to this was men's “Conception of the perinatal healthcare services being geared towards women.”44(p.7) A further category identifies that in terms of support, men want a male perspective that understands the paternal experience (category 15). One study found that “fathers want the information to be explicitly from the male perspective”41(p.61):

You know sometimes the women get that stuff about postpartum depression. I mean it says postpartum depression so who are they talking about, the mother's right? So you know women may get those brochures and whatnot but not for the dads. Maybe if some of that says, for the dad. I think if you want to reach the dad, then it has to be for the dads.41(p.61)

In reference to therapeutic support, it was also identified that “Fathers want therapists who understand what the father goes through.”41(p.63)

It was identified that men view perinatal depression as affecting mothers and feel stigma around fathers’ mental health problems (category 16). Participants described taboo and stigma, forming an unequivocal illustration for “paternal PPD as taboo”44(p.6):

… it is taboo44(p.6)

[…] people are afraid to say something [about their experiences with PPD]44(p.6)

They won’t open up because they are afraid that they get stigmatized […] as someone […] weak or inadequate.44(p.7)

Fathers did not know “men could suffer from postpartum depression.”36(p.1006) This also was consistent with the views of fathers in another study on “Believing that PPD is a gender specific condition”44(p.6):

Why should a man have [PPD]? He is not the one giving birth.44(p.6)

[My girlfriend and I] took the screening, but I thought that it was the girlfriend [who would show signs of perinatal depression]. I never thought that the father […] would go down with PPD.44(p.6)

It was found that “Stigma was a barrier to help seeking,”35(p.317) which was in part “driven by a reluctance to feel or be seen as weak or vulnerable.”35(p.317) Most concerning was the finding “Crisis point,”35(p.318) highlighted by one participant as being the point of help-seeking only when things were at rock bottom:

Personally I think I […] quite often end up seeking help when its when something's reached breaking point [mm] and there's no […] okay well I want to get you know get help to prevent breaking point [yea] and I probably imagine that that would be a common scenario.35(p.318)

This links back to findings around men seeking the GP when they had “marked symptoms,”42(p.6) highlighting late presentation for support for paternal mental health problems.

A positive observation was that screening was beneficial in encouraging some fathers to think about their symptoms and link these to depression (category 17). Again, screening was “an important part of the help seeking process”44(p.7) in terms of raising awareness of paternal perinatal depression:

When the health visitor told me that men also could get [PPD] [I thought] ‘Oh! You can?’44(p.7)

It is one thing that [my partner and I] have talked about me having a problem, and that I have a short fuse […] But now we have […] scientific evidence that I’m not all right.44(p.7)

[My general practitioner] tested me, [and] it was only then that I actually started to believe that I had [PPD].44(p.7)

However, whilst this was a credible illustration, the authors also noted that other fathers did not feel this significance,44 which explains the “some fathers” phrase in category 17. Despite this observation, one study also highlighted “the screening process as raising their awareness of their own symptomatology”35(p.315):

It does kind of twig you a little bit as well [mm] so yea so I did kind of think ooh actually I have felt a bit like that.35(p.315)

In addition to stigma and lack of awareness of paternal perinatal depression being barriers to help-seeking, the potential treatments were also a concern. The final category in this synthesized finding found that fathers do not want to seek support just to be prescribed medication for depression (category 18). Antidepressants were viewed particularly negatively. A specific finding was that men “Feared that seeking support would be met with a psychopharmacological response,”35(p.321) unequivocally illustrated by one father:

I didn’t want to […] all of a sudden go to the doctor and walk out with a prescription for antidepressants and be on them for the next twenty years I had a fear of [yea] becoming […] you know […] medicated.35(p.321)

This was mirrored by another study's participant:

[Anti-depressives] is not an option for me.44(p.7)

Synthesized finding 6: All men have the potential to struggle because fatherhood is challenging

The normative changes of fatherhood create physical and mental burdens for fathers, which start in pregnancy. Additional stressors, such as perinatal depression in the mother and breastfeeding difficulties, can be overwhelming. Men cope with these changes at home through the routine of work but also feel strained as the financial rock of the family.

This synthesized finding comprises 17 findings and four categories (see Table 7), and encompasses general fatherhood and the related stresses in relation to mental health. The first category contributing to this states that the pressures of fatherhood have negative effects on fathers’ mental and physical well-being (category 19). Numerous findings support this. Again, in line with the observation that men referred to their mental health experiences as stress,42 stress was a common element of the category: “A lack of sleep, missing meals and having to balance work commitments with family life were commonly reported triggers for tiredness and stress,”29(p.6) with one participant referring to sleep specifically:

It's tough ‘cause you’ve got - you’re not sleeping, you’re missing meals and like, I think those - that, for me, just missing the sleep and missing the meals, makes me more cranky and you just become a bit more snappier.29(p.6)

Table 7 - Synthesized finding 6
Findings Category Synthesized finding
A lack of sleep, missing meals and having to balance work commitments with family life were commonly reported triggers for tiredness and stress [C] 19. The pressures of fatherhood have negative effects on fathers’ mental and physical well-being. 6. All men have the potential to struggle because fatherhood is challenging. The normative changes of fatherhood create physical and mental burdens for fathers, which start in pregnancy. Additional stressors, such as perinatal depression in the mother and breastfeeding difficulties, can be overwhelming. Men cope with these changes at home through the routine of work but also feel strained as the financial rock of the family.
The additional stress resulting from the tiredness and pressure to provide for their family impacted negatively on several fathers [U]
The participants did not feel they had enough energy and mental strength to become the kind of fathers they wanted to be [C]
PND in men [C]
Physical and behavioural signs, including difficulty concentrating at work and suffering with headaches [C]
The lack of time the fathers felt were available to them given the new responsibilities in their lives [U]
Fathering was thwarted by the constraints generated by their partner's mental health [C] 20. Extra stressors are particularly problematic and include perinatal depression in the mother and breastfeeding problems.
Breastfeeding was a subject of concern [U]
Feelings of apprehension and nervousness appeared to be related to the ‘unknown’ about becoming a father [U] 21. Pregnancy is a time for apprehension and stress around what is to come.
Stress in the antenatal period [C]
If he is working more, he is staying out of her way and successfully providing for the family that he is responsible for [C] 22. Working provides fathers with an escape and somewhere to feel adequate, but they also feel stressed and financially responsible for their families.
They found focus on the work outside of the home to be a way to better cope with what was going on inside of the home [U]
Many new fathers found it very difficult to balance work and home life [C]
Guilt about being unable to support partner due to being at work [U]
Using work as a distraction [U]
Home suddenly had many negative associations and became a place in which they tried to avoid [C]
Uncertainty related to sick-leaves and dissatisfaction with work might have contributed to some distress [C]
U, unequivocal; C, credible; PND, postnatal depression

The finding “perinatal depression in men”43(p.392) also referred to a lack of sleep:

When you have had no sleep, you are pulling your hair out and you have bags under your eyes and you think, why have I bothered, why are we having a family, I don’t want to feel like this… is that depression? Could be, I don’t know.43(p.392)

Consistent with the effects of lack of sleep was “The additional stress resulting from the tiredness and pressure to provide for their family impacted negatively on several fathers,”29(p.6) which appeared to be illustrated in relation to lowered mood:

… it can bring you down very, very fast. Very difficult situation sometimes and yeah, an element of you can go into some form of a depressive state where, you know, you start to get frustrated at each other, because you’re both unaware what to do and your children are crying and it's like, what do we do?29(p.6)

The theme of tiredness continued through another finding where “participants did not feel they had enough energy and mental strength to become the kind of fathers they wanted to be”44(p.4):

There was this pressure […] I wanted to be there as a father, but I couldn’t. I wanted to be with my son […] but I couldn’t.44(p.4)

Pressure was also felt in relation to “The lack of time the fathers felt were available to them given the new responsibilities in their lives”41(p.57):

… who has time to lick your own wounds when you’re trying to tend to so many others.41(p.57)

The effects of new fatherhood on men's well-being were documented as “Physical and behavioral signs, including difficulty concentrating at work and suffering with headaches,”42(p.5) and were linked to help-seeking:

… something physically is going on, on top of the mental stress… I felt mentally drained as well and tired, but once the physical aspect came into the whole situation as well, that's when I went to the GP.42(p.5)

In addition to the tiredness and physical burden of fatherhood, other stressors were particularly problematic and included PND in the mother and breastfeeding problems (category 20). Men found their “Fathering was thwarted by the constraints generated by their partner's mental health,”40(p.725) with one father describing the impact of his partner's mental health difficulties on his mood:

There's no enjoyment, no fun, there's no [sigh], you can’t see a way out and all you can do is pitch in and try to stick it out and survive […] no fun, no happiness, no smiles.40(p.725)

Additionally, “Breastfeeding was a subject of concern.”44(p.5) Some participants described this in relation to their child's health:

[my daughter] wouldn’t eat because she was so weak […] on the seventh day [after delivery] we had a child who looked like a skeleton. [She] was completely weakened.44(p.5)

… what can I do, really? […] No matter how many times I run up and down the stairs, she won’t necessarily put on weight.44(p.5)

Clearly, fatherhood posed stresses for fathers. One category found that this arose from pregnancy, where pregnancy is a time for apprehension and stress around what is to come (category 21). One study referred to “Stress in the antenatal period,”29(p.5) where a father used a metaphor for emotional changes:

… a rollercoaster ride…we’ve got a long way to go yet until the baby arrives in this world and having that mixed emotions, really, so there's been stressful times.29(p.5)

In particular, “Feelings of apprehension and nervousness appeared to be related to the ‘unknown’ about becoming a father”29(p.5):

Excitement was probably the first thing that I felt…it was a little bit of, kind of, apprehension, as in how–what will I need to, kind of, do in terms of being a dad.29(p.5)

Pretty scary, overwhelming, life-changing.29(p.5)

One of the most significant categories in terms of findings of similar meanings was around work: working provides fathers with an escape and somewhere to feel adequate, but they also feel stressed and financially responsible for their family (category 22).

The role of work was multifaceted. It comprised maintaining a role as provider, but in a way that also contributed to the relationship. This was embodied in the finding: “If he is working more, he is staying out of her way and successfully providing for the family that he is responsible for.”41(p.59) This same study further demonstrated men's efforts to try to do the right thing despite how this may appear to others:

The message for me at least, sort of the implicit in that is the assumption that the behavior that you’re seeing may look unsupportive and has the intent of being unsupportive. I don’t think it always does, but sometimes I think a husband for example may start working a lot more. They may feel like o my gosh I need to make more money, so it can be really easy to label them as sort of the withdrawn, deadbeat opportunistic husband. As anything moving forward, I think what husband isn’t going to walk towards something that's labeling him in that way.41(p.60)

Work also provided fathers with distraction from the challenging experiences of raising a small baby at home: “They found focus on the work outside of the home to be a way to better cope with what was going on inside of the home.”41(p.60) This finding was unequivocally illustrated to demonstrate men's attempts to use work to manage the difficulties of fatherhood:

I have three mouths to feed so I had to get to it and I had to get to work and that was that.41(p.60)

So, I just went on about my work, trying to work, work, work.41(p.60)

Similarly, fathers described “Using work as a distraction”42(p.9):

I like my work because it's technical stuff, I know I can bury myself in it and that will take my mind off it.42(p.9)

This distraction represented avoidance of the reality of home in the finding “Home suddenly had many negative associations and became a place in which they tried to avoid.”44(p.5) Here, fathers clearly described work as a tool of avoidance or something that restored good feeling:

I mostly used work to escape […] because I knew that I would come back home to a screaming kid and a moody wife.44(p.5)

The only place I actually feel good is when I am at work.44(p.5)

However, despite these functional elements of work in the perinatal period, work also acted as a burden, contributing to stress and negative emotional experiences, including guilt and distress. “Many new fathers found it very difficult to balance work and home life,”29(p.6) with one participant describing what seemed like a never-ending cycle:

You give her a feed and you put her to bed and then you unwind, if you can or you don’t, and then you go to sleep. And then you’ll know like at 12 o’clock or 3 o’clock she’ll wake up and you’ll have to feed her. And that's the really difficult time. … ‘cause you’re exhausted from work, and then like, during that period you know something's going to happen. So, you have to care for her then and then, you have to wake up again at 6 o’clock to get ready for work again. And then, you’re doing your eight or nine hours at work and you come back and it's–you’re doing that same cycle.29(p.6)

They also felt “Guilt about being unable to support partner due to being at work”42(p.5):

I felt guilty actually, guilty going back to work and leaving [partner] with everything… I was like, I’ve left them all day on their own. I don’t think that's how she felt but that's how I felt.42(p.5)

Additionally, problems with work created extra burden, with “Uncertainty related to sick-leaves and dissatisfaction with work might have contributed to some distress.”44(p.5) In discussing paternal PPD, one participant speculated that work was a cause of his difficulties:

I felt, that [my job situation] was where it all originated from.44(p.5)

Discussion

This qualitative systematic review aimed to understand fathers’ experiences of depression in the perinatal period. It was identified that depression was poorly understood among fathers, but that they experienced difficult feelings, including irritability and anger, as well as inadequacy and shame. Often, they referred to these emotions as “stress.” A further objective was to understand fathers’ recognition and understanding of their perinatal depression. This review identified that men's mental health literacy around their depression was poor, and that fathers normalized their experiences, considering them to be a natural part of fatherhood. Despite this, some had a sense of changed feelings.

The role of fathers’ relationships with partners and infants was likewise complex. For instance, they felt a pressure to hide their symptoms to protect their partner. Some men felt angry and resentful of their infant and irritable towards the partner, but largely, the partner's and infant's well-being was a motivator to seek help, with partners being significant in their help-seeking. There was a notable lack of father-specific support across the studies. These findings are important since three-fourths of deaths by suicide in the UK are by men,45 yet PPD has been considered a women's condition.46 This discussion will examine the findings in the context of the existing research.

Other papers on paternal perinatal depression were identified, but they were excluded based on the inclusion/exclusion criteria. In a previous systematic review focusing on fathers’ experiences of perinatal depression,17 two papers on fathers’ depression experiences were included that differ from those in this review. In one of these, 19 fathers were purposively sampled based on their completion of two screening tools (EPDS and GMDS) and demonstrated a score indicative of depression.19 This paper was not included in the current review because it was based on an intervention for depression, but also because some participants directly referred to infants being born “disabled or ill.”19(p.433) The other paper aimed to explore fathers’ psychological experiences of fatherhood and, while they held a focus group to inform the interview schedule, only one father was interviewed as a case study.18 This was excluded due to reference to the participants’ past recurrent miscarriages. However, despite the differences between that review17 and this one, the findings are consistent with some of the synthesized findings in this review, strengthening their validity, and these are embedded in the discussion of our relevant findings, which are discussed under two headings: depression in fathers and help-seeking in fathers.

Depression in fathers

Poor health literacy around paternal perinatal depression

This review identified that mental health literacy around paternal perinatal depression was poor among men, which is concerning given that antenatal and postnatal care pathways are limited to mothers.1 This finding supports wider research recognizing poor health literacy for both depression in men24 and paternal PND.25 One study found that men's depressive symptoms were “poorly understood”47(p.524) in general, and this was consistent with the findings of this review, particularly with regard to how men experience depression perinatally. Despite this, fathers recognized a change in themselves, understanding “that something is wrong,”44(p.6) which suggests some literacy around feelings and emotions. Recognition of mental health difficulties sometimes occurred through a discussion with men's partners.42 As such, despite paternal perinatal depression literacy being limited, there is some awareness and partners can support this.

“Stress” was a common theme across studies, consistent with the observation that stress was often how men referred to their perinatal mental health elsewhere.42 This review identified inadequacy as commonly felt among men, which is significant since another study found their participants referring to inadequacy as stress.48 What was clear across the studies, however, was that men experienced mental distress in the perinatal period. This was specific with regard to the emotions men experienced, including stress, powerlessness, negative emotions, feeling trapped, and shame. The difference between perceptions and the realities of fatherhood, and the difficulties that arose from this, caused them to feel inadequate. It is, therefore, possible that fathers feeling inadequate or stressed in the perinatal period may in fact be experiencing depression.

Anger and irritability as symptoms of father mental distress

A key observation relates back to research that stated that depression and anger coexist in the postnatal period.22 Anger and irritability were identified in numerous studies as symptoms of fathers’ depression (in the cases of those studies focusing specifically on perinatal depression)36,44 or of their mental health experiences in the less-specific studies.41,42 This demonstrates that, while perinatal depression in women may be considered in the case of low mood or tearfulness, the presentation may be different with men. What was particularly striking was the honesty with which online narratives were represented,36 and it is significant that it was only within a study of anonymous forum chat users that fathers acknowledged a desire to harm their child, hatred towards their partners, and the fact they resented their children. This demonstrates new knowledge in terms of the intensity of men's feelings of anger.

Despite this, another online questionnaire offered anonymity,37 yet irritability or anger were not presented as findings. However, the focus of the study was on support for men's mental health in the case of mothers with poor mental health. The present review found that men feel reluctant to seek help when their partner is struggling, and it is possible this translates into their approach to research. Furthermore, in situating their needs around those of the mother, men may not disclose irritability or anger in the instances where their partner is a key aspect of the question-asking. This highlights a clear need for anonymous questioning directly around irritability and anger in fathers. Such irritability is also identified in the wider literature.49 In another study on telephone calls to an Australian perinatal support helpline, 15% of callers “discussed their own feelings of anger and frustration,”50(p.153) which was notably also an anonymous setting.

Negative emotions and feelings commonly experienced

This review identified numerous emotions and feelings fathers exhibited in relation to their perinatal mental health difficulties. These included confusion,37 exhaustion,29,36,44 tiredness,29,42,44 and feeling alone.29,36 Many felt powerless,40,42,44 trapped,36,40,44 isolated,37,41 neglected,36,44 forgotten,36 helpless,36,41 ashamed,44 and hateful.36 Whilst not all of these would be consistent with assessment tools (eg, the EPDS), they are clearly negative, and suggest that wider questioning around distressing emotions in fathers would be productive in supporting their mental health. Conflicting with these was a feeling of unreality, which was also commonly identified in relation to the change to fatherhood.29,42 Aggression and irritability were identified in this review and are included in the Gotman Male Depression Scale, but this is not universally used within current perinatal mental health care as a screening tool in the UK,1 perhaps due to fathers not currently being screened.2

Relating to the research question on relationships in the perinatal period, some emotions were specifically connected to men's intimate relationships. Regarding perinatal depression, this review found that fathers experienced relationship changes as a source of distress, mirroring the wider literature where men also struggle with deterioration in their intimate relationships.18,19,48,50 In particular, such changes resulted in men feeling withdrawn, isolated, and less connected. This parallels other studies where a lack of sexual intimacy causes a source of strain in relationships.18,48 “Changes to sexual relationships”14 was also identified in a systematic review into the mental health and well-being of first-time fathers.

Coping with difficult feelings

The review identified that fathers in the perinatal period do experience depression, but tend to avoid, hide, or normalize their feelings. Similar to how their relationships became more distant, fathers became withdrawn and isolated in general,41,42 yet also attempted to normalize their difficulties as typical in fatherhood.44 It is possible that this is a mechanism to protect the partner, considering men's prioritization of their partner within the help-seeking context, but is also instrumental when denying their depression. Gender also had a role in men's recognition of their depression or mental distress, because they largely viewed perinatal depression as a condition only affecting the mother,44 which supports the same observation elsewhere.46 When considering how men experience difficult feelings, it was identified in another study that 55% of fathers experience poor mental health for the first time in the postpartum period.51 However, men with a previous history of mental ill-health had more awareness of their symptoms,51 suggesting that the risk of depression remaining unrecognized and untreated, and the use of coping mechanisms such as avoidance and normalization, may be higher in men with no mental health history.

Help-seeking in fathers

Lack of parity around paternal support in comparison to mothers

Support for fathers is inconsistent across the UK, and a recent good-practice guide offers guidance on asking about paternal mental health and potential support,52 though this does not formally cover Scotland, Wales, or Northern Ireland. In comparison, mothers are supported with perinatal mental health in line with national guidance.1 This disparity was experienced by numerous fathers, who labeled it as an “extreme imbalance.”37(p.6)

An important observation was that men seek help when at crisis point. This was supported by findings that when calling a helpline for parents, men felt at a “breaking point.”50(p.152) This reflects recent literature on men's help-seeking for depression in general, with another study concluding that long-term depression alone was not enough for men to “overcome actual or perceived help-seeking barriers for depression,”53(p.533) and suggesting that these men may not have felt their long-term depression was sufficient to justify seeking help.53

Fathers fearful of seeking help for how they may appear to others

A further finding was that fathers felt judged about mental health difficulties so are reluctant to disclose them. Fathers fear looking weak or vulnerable when seeking help in the perinatal period.35 Wider literature offers further insight into this. Another study found that some men preferred to consult “other men who had or were already parents as having appropriate authority”54(p.50) when seeking support. This consistent with a study where participants identified peer support as a favorable form of support.55

Strengths and limitations

Across the studies, a total of 138 fathers contributed data through interviews, surveys, and online forums. This was synthesized to produce six findings, which offer new insights into how fathers experience depression in the perinatal period, and increase understanding of their help-seeking during this time. However, potential limitations of these studies within the context of this review included their content: despite the focus on fathers and the rich descriptions of their experiences produced across the studies, in all the qualitative interview studies,29,35,40-44 interviewers were women (except for one study where two researchers carried out the interviews and one was a man).42 This potentially creates a dynamic where men are not speaking to “one of their own,” but rather, a female researcher. Given men's feelings around maternity and perinatal services being female-centric, it is possible that these feelings may extend into the research, whereby men feel they must only voice answers that are acceptable to a woman. The potential implications on the data have not been considered in all the studies, and are represented by an “unclear” or “no” answer in the JBI critical appraisal tool.34

Additionally, some men were interviewed with their partners present29,42 or as joint interviews.43 In some cases, men were interviewed in their homes, risking the partner overhearing their narratives. Despite only the father's voice being used in the review, there is pressure on the father to only reveal what is acceptable to his relationship at the time. In the data, men clearly identified gendered social expectations of them as fathers, a distance from their partners, and taking an attitude of coping alone. It is possible that they maintained this during interviews. Referring to the researchers also being women, those interviews completed with two women were likely to have produced different data than if a father had interviewed a father.

Interviews as a method of data collection in themselves pose issues. The online studies using surveys and analyses of chat forum text36,37 were more vivid in terms of their descriptions of depression. A methodological limitation that the authors already acknowledged is that the accuracy of these cannot be substantiated because of the anonymity of the forum. Yet, this also acts as a benefit in terms of richness of data and is something that offers a new approach to future research on both men's health and mental illness in the context of fatherhood.

In terms of sample characteristics, these were adequate for a qualitative review, although situating the findings within quantitative literature means that the prevalence of paternal perinatal depression cannot be confirmed or denied. However, this was never the intention of a qualitative systematic review. The samples were also limited in terms of socio-demographic characteristics, with most participants being White and all from OECD nations. This is important, as it is unclear to what extent the present findings may represent the experiences of fathers from marginalized social identity groups (eg, racial[ised] minority men and men from non-OECD countries). Indeed, more research is urgently needed to better represent the experiences of fathers from more diverse socio-demographic backgrounds, particularly those backgrounds that have been historically marginalized and/or rendered invisible in the academic literature. A further limitation is that, despite a highly specific, comprehensive search process across a range of sources, based on keywords and content of relevant literature, seven of the included papers focused on paternal mental health in general, rather than paternal perinatal depression. This highlights a need for further research into paternal depression within the perinatal period specifically.

Conclusions

This review offers new knowledge when understanding fathers’ experiences of depression in the perinatal period. It identified that fathers’ experiences are embedded in their emotions, their relationships, and their help-seeking practices. The PROSPERO protocol was adhered to, although inclusion and exclusion criteria for studies required amendment. Nevertheless, some gaps were left, such as the experience of racial minority fathers, and possibly different experiences between first-time and subsequent fathers.

Recommendations for practice

In the UK, perinatal mental health is prioritized in numerous policies, including the National Health Service (NHS) Long Term Plan,56 which considers support for both parents up to two years postnatally. However, at the point of writing, there is no UK universal care pathway for assessment or management of paternal mental health57 and this includes perinatal depression. As such, we are able to make a number of recommendations for practice58 based on the findings of this review.

Firstly, it is necessary to consider the context when fathers present to services with depression. It has been acknowledged that depression is experienced differently in the perinatal period, specifically around the emotions experienced. As such, when GPs (the profession of choice for men's help-seeking in this review) encounter men with depression, they should consider if patients are presenting during the perinatal period of fatherhood (Grade B).

Secondly, fathers are suspicious of health visitors and fear removal of their child if they disclose depression. Training of health visitors to deliver transparent, sensitive care to fathers would be beneficial in order to build relationships and encourage fathers to view them as supportive professionals, to improve the outcome of the whole family. Including support around relationships in the perinatal period would also be beneficial. The father's partner should also be considered significant in his help-seeking (Grade B).

Recommendations for research

Despite this review producing synthesized knowledge on paternal perinatal depression, only two of the papers focused specifically on perinatal depression, and one of these was an investigation into online forum narratives.36 Based on the findings of this review, and the lack of relevant studies, more research is required in the areas of both paternal perinatal depression and men's help-seeking in the perinatal period. Given the significance of partners in recognizing fathers’ changed mood, studies with partners (the mother of the child) would offer new insights into the condition.

Screening was identified as beneficial to some fathers when it came to identifying their perinatal depression. Development of a father-focused screening tool for depression has not yet been designed. It is recommended that a screening tool be developed, taking into account the emotions identified here, acknowledging that depression symptoms may not be limited only to those in diagnostic manuals (eg, the DSM-5 or the ICD-11), but can differ from how depression is currently conceptualized clinically.

Suicidal feelings were outlined,44 which supports findings demonstrating that suicide risk for men is increased for depressed fathers during the postpartum period.7 Whilst a study identified fathers of babies as feeling suicidal,50 research into paternal suicide is scarce. Only two studies focused on paternal perinatal depression,36,44 yet the majority of deaths by suicide in the UK are men.45 This highlights an urgent need into research focused on the relationship between suicidal feelings and paternal depression, including qualitative research.

Additionally, given the disparities in care felt by men, and failure by health professionals and health systems to ask men routinely about their mental health, it is also necessary to produce research from a practitioner perspective. Given that health visitors (specialist community public health nurses working with families of young children aged 0-5 years) offer a universal service (offered on a basic level to all families, with targeted support offered in the case of identified need) in the UK,59 three points of interest are particularly relevant. First, the men in this review viewed health visitors with suspicion.44 Exploring health visitors’ perspectives on safeguarding practices with regard to fathers’ mental health could provide insight into the processes involved when a father discloses depression. Second, this review identified that fathers felt health visitors did not value the father in their care,37 so insight into health visitors’ attitudes towards fathers would be of interest. Third, one study highlighted that health visitors were not the professional of choice for support.29 Men preferred the GP,29 but were also noted to present with more severe symptoms,42 so concurrent research into GP perceptions of paternal PND would also be valuable.

Acknowledgments

Andrea Packwood, Anglia Ruskin University librarian, for her support in developing the search strategy. Professor Kay Cooper from The Scottish Centre for Evidence-Based, Multi-professional Practice: A JBI Centre of Excellence for her guidance in using the JBI approach to systematic reviews of qualitative studies, and for reviewing the protocol.

This review contributes to a doctoral degree award for CD.

Funding

This systematic review has been completed as part of a fully funded Vice Chancellor PhD studentship at Anglia Ruskin University for CD.

Author contributions

CD contributed to the conceptualization, methodology, formal analysis, data curation, and writing (original draft, reviewing, and editing). JL contributed to the formal analysis and writing (reviewing and editing). CO contributed to the formal analysis and writing (reviewing and editing). VS contributed to the conceptualization, formal analysis, writing (reviewing and editing), supervision, project administration, and funding acquisition.

Appendix I: Search strategy

MEDLINE (EBSCO)

Search conducted on August 9, 2021.

figure4
figure5

CINAHL (EBSCO)

Search conducted August 9, 2021.

figure6
figure7

PsycINFO (EBSCO)

Search conducted August 9, 2021

figure8
figure9

Scopus

Search conducted August 9, 2021

figure10

ProQuest Sociology

Search conducted August 9, 2021.

figure11

ProQuest Dissertations and Theses Global

Search conducted August 9, 2021

figure12

OpenGrey

Search conducted August 9, 2021

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Appendix II: Studies ineligible following full-text review

1. Åsenhed L, Kilstam J, Alehagen S, Baggens C. Becoming a father is an emotional roller coaster—an analysis of first-time fathers′ blogs. J Clin Nurs. 2014;23(9–10):1309–17.

Reason for exclusion: Phenomenon not depression (focus is fatherhood in general).

2. Bäckström C, Thorstensson S, Mårtensson LB, Grimming R, Nyblin Y, Golsäter M. “To be able to support her, I must feel calm and safe”: pregnant women's partners perceptions of professional support during pregnancy. BMC Pregnancy Childbirth. 2017;17(1):234.

Reason for exclusion: Phemonenon not depression (focus is fatherhood in general).

3. Barnard M. Fathers’ emotional work deserves more attention from health professionals. Nurs Child Young People. 2014;26(5):13.

Reason for exclusion: Ineligible method (research commentary only).

4. Barnes, C. What postpartum depression looks like for men: a phenomenological study [thesis]. Walden University [internet]. 2019 [cited 2021 Sep 7]. Available from: https://scholarworks.waldenu.edu/dissertations/6774/.

Reason for exclusion: Ineligible method (qualitative data descriptive only)

5. Bennett, E, Cooke, D. Surviving postnatal depression: the male perspective. Neonatal Paediatr Child Health Nurs. 2012;15(3):15-20.

Reason for exclusion: Phenomenon not depression (focuses on father's perspectives of the mother).

6. Chin R, Daiches A, Hall P. A qualitative exploration of first-time fathers’ experiences of becoming a father. Community Pract. 2011;84(7):19–23.

Reason for exclusion: Phenomenon not depression (focus is fatherhood in general).

7. Davies J. Completing the maternity jigsaw. Pract Midwife. 2008;11(11): 12–14.

Reason for exclusion: Not available.

8. Driesslein A. From the “technician thing” to the “mental game”: masculinity and U.S. Homebirth. Med Anthropol Q. 2017;31(4):464–80.

Reason for exclusion: Phenomenon not depression (focus is masculinity).

9. Edhborg M, Carlberg M, Simon F, Lindberg L. “Waiting for better times”: experiences in the first postpartum year by Swedish fathers with depressive symptoms. Am J Mens Health. 2016;10(5):428–39.

Reason for exclusion: Ineligible population (past perinatal loss). Also linked to an intervention.

10. Eriksson H, Salzmann-Erikson M. Supporting a caring fatherhood in cyberspace - an analysis of communication about caring within an online forum for fathers. Scand J Caring Sci. 2013;27(1):63–9.

Reason for exclusion: Phenomenon not depression (focus is fatherhood in general).

11. Fägerskiöld A. A change in life as experienced by first-time fathers. Scand J Caring Sci. 2008;22(1):64–71.

Reason for exclusion: Phenomenon not depression (focus is natural emotions of fathers)

12. Fenton S, Joscelyne T, Higgins S. Part 1: exploring views from fathers and perinatal practitioners on the inclusion of fathers by perinatal services. Br J Midwifery. 2021;29(4):208–15.

Reason for exclusion: Ineligible method (does not discuss qualitative findings).

13. Fenwick J, Bayes S, Johansson M. A qualitative investigation into the pregnancy experiences and childbirth expectations of Australian fathers-to-be. Sex Reprod Healthc. 2012;3(1):3–9.

Reason for exclusion: Ineligible population (past perinatal loss)

14. Finn M, Henwood K. Exploring masculinities within men's identificatory imaginings of first-time fatherhood. Br J Soc Psychol. 2009;48(3):547–62.

Reason for exclusion: Phenomenon not depression (focus is masculinity and fatherhood).

15. Finnbogadóttir H, Svalenius E, Persson EK. Expectant first-time fathers’ experiences of pregnancy. Midwifery. 2003;19(2):96–105.

Reason for exclusion: Phenomenon not depression (focus is fatherhood in general).

16. Fletcher R, St George J, Newman L, Wroe J. Male callers to an Australian perinatal depression and anxiety help line-Understanding issues and concerns. Infant Ment Health J. 2020;41(1):145–57.

Reason for exclusion: Ineligible method (qualitative data is descriptive only).

17. Hambidge S, Cowell A, Arden-Close E, Mayers A. “What kind of man gets depressed after having a baby?” Fathers’ experiences of mental health during the perinatal period. BMC Pregnancy Childbirth. 2021;21(1):463.

Reason for exclusion: Ineligible population (severe mental illness diagnoses).

18. Henshaw EJ, Cooper MA, Jaramillo M, Lamp JM, Jones AL, Wood TL. “Trying to figure out if you’re doing things right, and where to get the info”: parents recall information and support needed during the first 6 weeks postpartum. Matern Child Health J. 2018;22(11):1668–75.

Reason for exclusion: Phenomenon not depression (focus is transition to fatherhood in general and support needs).

19. Ierardi JA, Fantasia HC, Mawn B, Watson Driscoll J. The experience of men whose partners have postpartum depression. J Am Psychiatr Nurses Assoc. 2019;29(6):434-44.

Reason for exclusion: Ineligible population (severe mental illness diagnoses).

20. Ierardi JA. Exploring the experiences of men whose partners have postpartum depression [dissertation]. Lowell, MA: University of Massachusetts Lowell.

Reason for exclusion: Ineligible population (severe mental illness diagnoses).

21. Johansson M, Hildingsson I, Fenwick J. Important factors working to mediate Swedish fathers’ experiences of a caesarean section. Midwifery. 2013;29(9):1041–9.

Reason for exclusion: Phenomenon not depression (focus on birth experiences).

22. Johansson M, Benderix Y, Svensson I. Mothers’ and fathers’ lived experiences of postpartum depression and parental stress after childbirth: a qualitative study. Int J Qual Stud Health Well-being. 2020;15(1):1–11.

Reason for exclusion: Ineligible population (traumatic birth and past perinatal loss).

23. Kayser JW, Semenic S. Smoking motives, quitting motives, and opinions about smoking cessation support among expectant or new fathers. J Addict Nurs. 2013;24(3):149–57.

Reason for exclusion: Phenomenon not depression (focus is smoking in fathers).

24. Kowlessar O, Fox JR, Wittkowski A. First-time fathers’ experiences of parenting during the first year. J Reprod Infant Psychol. 2015;33(1):4–14.

Reason for exclusion: Phenomenon not depression (focus is fatherhood in general).

25. Kwon J-Y, Oliffe JL, Bottorff JL, Kelly MT. Heterosexual gender relations and masculinity in fathers who smoke. Res Nurs Health. 2014;37(5):391–8.

Reason for exclusion: Phenomenon not depression (focus is masculinity).

26. Letourneau N, Duffett-Leger L, Dennis C-L, Stewart M, Tryphonopoulos PD. Identifying the support needs of fathers affected by post-partum depression: a pilot study. J Psychiatr Ment Health Nurs. 2011;18(1):41–7.

Reason for exclusion: Ineligible population (past perinatal loss).

27. Letourneau N, Tryphonopoulos PD, Duffett-Leger L, Stewart M, Benzies K, Dennis C-L, et al. Support intervention needs and preferences of fathers affected by postpartum depression. J Perinat Neonatal Nurs. 2012;26(1):69–80.

Reason for exclusion: Ineligible population (includes adoptive and stepfathers).

28. Madsen SA. Men's mental health: fatherhood and psychotherapy. J Mens Stud. 2009;17(1):15–30.

Reason for exclusion: Ineligible method (qualitative data is descriptive only).

29. Mizukoshi M, Ikeda M, Kamibeppu K. The experiences of husbands of primiparas with depressive or anxiety disorders during the perinatal period. Sex Reprod Healthc. 2016;8:42-8.

Reason for exclusion: Phenomenon not depression (focus on maternal mental illness).

30. Muscat T, Thorpe K, Obst P. Disconfirmed expectations of infant behaviours and postnatal depressive symptoms among parents. J Reprod Infant Psychol. 2012;30(1):51-61.

Reason for exclusion: Ineligible method (quantitative study).

31. Newmark E. Paternal depression: manifestations and impacts on the family [dissertation]. San Diego, CA: Alliant International University.

Reason for exclusion: Ineligible population (participants are not fathers).

32. Oates MR, Cox JL, Neema S, Asten P, Glangeaud-Freudenthal N, Figueiredo B, et al. Postnatal depression across countries and cultures: a qualitative study. Br J Psychiatry. 2004;184(46):10-16.

Reason for exclusion: Ineligible context (not limited to Organisation for Economic Co-operation and Development [OECD] countries).

33. Pålsson P, Persson EK, Ekelin M, Kristensson Hallström I, Kvist LJ. First-time fathers experiences of their prenatal preparation in relation to challenges met in the early parenthood period: implications for early parenthood preparation. Midwifery. 2017;50:86–92.

Reason for exclusion: Ineligible context (some study cites based in non-OECD countries).

34. Premberg Å, Hellström A, Berg M. Experiences of the first year as father. Scand J Caring Sci. 2008;22(1):56–63.

Reason for exclusion: Phenomenon not depression (focus is fatherhood in general).

35. Premberg Å, Carlsson G, Hellström A-L, Berg M. First-time fathers’ experiences of childbirth--a phenomenological study. Midwifery. 2011;27(6):848–53.

Reason for exclusion: Phenomenon not depression (focus is experiences of childbirth).

36. Rominov H, Giallo R, Pilkington PD, Whelan TA. “Getting help for yourself is a way of helping your baby:” Fathers’ experiences of support for mental health and parenting in the perinatal period. Psychol Men Masc. 2018;19(3):457–68.

Reason for exclusion: Phenomenon not depression (focus on support experiences but not specifically around depression).

37. Rowe HJ, Holton S, Fisher JRW. Postpartum emotional support: a qualitative study of women's and men's anticipated needs and preferred sources. Aust J Prim Health. 2013; 19(1):46-52.

Reason for exclusion: Phenomenon not depression (reviewers agreed that the focus on paternal emotional support needs are not specific around depression to include).

38. Sarkar SP. ‘Post-natal’ depression in fathers, or Early Fatherhood Depression. Psychoanalysis. 2018;32(2):197-216.

Reason for exclusion: Ineligible method (case history written from a clinical perspective).

39. Scheibling C. Doing fatherhood online: men's parental identities, experiences, and ideologies on social media. Symb Interact. 2020;43(3):472–92.

Reason for exclusion: Ineligible context (not perinatal period).

40. Shezifi O. When men become fathers: a qualitative investigation of the psychodynamic aspects of the transition to fatherhood [dissertation]. San Diego, CA: Alliant International University.

Reason for exclusion: Phenomenon not depression (focus on transition to fatherhood).

41. Teague SJ, Shatte ABR. Peer support of fathers on Reddit: quantifying the stressors, behaviors, and drivers. Psychol Men Masc. 2021;22(4):757-66.

Reason for exclusion: Ineligible method (qualitative data is descriptive).

42. Thombs BD, Roseman M, Arthurs E. Prenatal and postpartum depression in fathers and mothers. JAMA. 2010;304(9):961.

Reason for exclusion: Ineligible method (letter to editor).

43. Thompson SD, Crase SJ. Fathers of infants born to adolescent mothers: a comparison with non-parenting male peers and adolescent mothers. Child Youth Serv Rev. 2004;26(5):489–505.

Reason for exclusion: Ineligible population (age under 18 years).

44. Thorstensson S, Mårtensson LB, Bäckström C, Grimming R, Nyblin Y, Golsäter M. “To be able to support her, I must feel calm and safe”: pregnant women's partners perceptions of professional support during pregnancy. BMC Pregnancy Childbirth. 2017;17:1–11.

Reason for exclusion: Phenomenon not depression (focus on fatherhood in general).

45. Widarsson M, Kerstis B, Sundquist K, Engström G, Sarkadi A. Support needs of expectant mothers and fathers: a qualitative study. J Perinat Educ. 2012;21(1):36-4.

Reason for exclusion: Phenomenon not depression (focus on parenthood in general).

Appendix III: Characteristics of included studies

figure14
figure15
figure16

Appendix IV: Study findings and illustrations

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figure18
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figure20
figure21
figure22
figure23
figure24
figure25
figure26
figure27

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Keywords:

depression; father; paternal; perinatal; postnatal

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