Fatherhood Institute Research Summary: FATHERS AND POSTNATAL DEPRESSION

10 August 2010

Messages from Research
Updated August 2010

1. The father’s role in mothers’ depression

The evidence that impaired postnatal maternal mental health has adverse effects on the infant socially, emotionally, behaviourally and cognitively is extensive (e.g. Kurstjens & Wolke, 2001; Cummings & Davies, 1994; Hossain et al, 1994). Amelioration of the mother’s psychological distress after the first year does not necessarily improve the outcome for the child (Murray et al, 2003).

Mothers’ depression is associated with own personality, perinatal, infant-related, partner-related and other factors. The partner-related factors include a poor relationship with the baby’s father, his being unavailable at the time of the baby’s birth and his provision of what is perceived by the mother to be insufficient emotional or practical support. This can include low participation in infant care. Other risk factors include his holding rigid sex-role expectations, or being critical, coercive or violent (for review, see Fisher et al, 2006).
The father’s functioning as a support person is key, since depressed new mothers are more likely to turn to and receive support from their partner than from any other individual, including medical staff (Holopainen, 2002). Today, 70% of new mothers turn to their partners for emotional support, compared with only 47% in the 1960s (GMTV survey, 2009).

2. Fathers’ own depression: prevalence

While the study of new fathers’ depression is still in its infancy (Wee et al, 2010) our understanding of it has advanced considerably in the past ten years (Schumacher et al, 2008). As is the case with maternal depression, estimates of paternal depression vary widely depending on the characteristics of the sample and the measure of depression used.

• New fathers’ depression rates have been found to be double the national average for men in the same age group in Denmark (Madsen et al, 2006) and also in the US (Paulson et al, 2006)

• First time fathers may be particularly prone to depression (Cowan et al, 1991) with mild to moderate depression most likely (Soliday et al, 1999) and no recorded increase in severe mental disorders (Munk-Olsen et al, 2006).

• A meta-analysis (43 studies) found an average 10.4% of fathers depressed both pre- and post-natally, with the peak time for fathers’ depression being between three and six months after the birth (Paulson & Bazemore, 2010).

• Although pregnancy is a period of greater stress for fathers than the post-birth period (Huang & Warner, 2005; Condon et al, 2004), one study found fathers’ rates of depression to be higher after the birth than before it (Huang & Warner, 2005). Another study (Ramchandani et al, 2008) found no pre- post-birth depression differences, but here fathers’ depression postnatally was measured only at eight weeks – which, as mentioned above, is not the peak time for paternal depression.

• Ramchandani et al (2008) found half of the men who were depressed before the birth also depressed eight weeks afterwards, suggesting ‘chronicity’ in a substantial percentage of cases.

3. Fathers’ depression: associated factors

• Infant-related problems (Dudley et al, 2001). For instance, sleeping/crying problems are linked with fathers’ as well as mothers’ depression (Smart & Hiscock, 2007) although the direction of effects is uncertain.

• The father’s neuroticism and substance abuse/dependence (Huang & Warner, 2005).

• The mother’s personality difficulties, unresolved past events in her life and her current mental health status (Huang & Warner, 2005).

• The father’s own previous history of severe depression and his high prenatal symptom scores for depression and anxiety (Ramchandani & Stein, 2008).

• The experience of a general lack of support and a poor quality couple relationship, including disagreement about the pregnancy and perceived lack of supportiveness from the mother (Escribà-Agüir & Artazcoz, 2010; Bronte-Tinkew et al, 2009; Huang & Warner, 2005; Dudley et al, 2001; Matthey et al, 2000).

• A recent systematic review (Wee et al, 2010) identified low relationship satisfaction as key – and also having a partner with elevated depressive symptoms.

• This last has also been found in other studies: a recent meta-analysis (Paulson & Basemore, 2010) found a moderate but clear correlation between maternal and paternal depression, with direction of influences not known.

• And an integrated review of 20 research studies found 24-50% of new fathers with depressed partners affected by depression themselves (Goodman, 2004).

• In a later study (Goodman, 2008) continued to find a correlation between mothers’ and fathers’ depression, and also found increased parenting stress in the fathers..

• Another study not only recorded more depressive symptoms among men whose partners were depressed but also more aggression and non specific psychological impairment, as well as higher rates of depressive disorder, non specific psychological problems and problem fatigue. Three or more co-morbid psychological disturbances were common. On measures of anxiety and alcohol use there was no difference between men whose partners were depressed and men whose partners weren’t (Roberts et al, 2006).

• Two earlier studies (Lovestone & Kumar, 1993; Harvey & McGrath, 1988) found that where mothers were hospitalized with a severe post-partum psychological disorder, 42% of their male spouses also had a psychological disorder – compared with 4% in a community sample and 0% among new fathers whose partners did not have a post-partum mental illness.

• A study of Japanese new parents found no correlation between mothers’ and fathers’ depression (this may be a culturally specific finding, or a feature of this particular study) but found a strong link with the father’s unemployment and – as many other studies have found – with unintended pregnancy (Nishimura & Ohashi, 2010).

Low income new fathers, including young fathers are particularly vulnerable to depression, seemingly due to interacting factors. In a low income African American sample, 56% of new fathers were found to have ‘depressive symptoms indicating cause for clinical concern’. Correlates included resource challenges, transportation and permanent housing difficulties; problems with alcohol and drugs; health problems/disability; and a criminal conviction history (Anderson et al, 2005).

In this study, and in opposition to findings elsewhere, higher levels of social support were associated with greater depressive symptomatology, leading researchers to speculate that for these low-income men the perceived costs of reciprocity may have deterred them from utilizing available support; or that peer groups may have influenced their alcohol or drug use, or placed demands on their resources (Anderson et al, 2005).

The more tenuous the relationship with the mother, the more likely it is that the father will be depressed. Interacting factors and selection effects would seem to explain this in part, but the circumstances of the pregnancy are also likely to be relevant. Rates of paternal depression in one recent US study were 6.6% (married fathers), 8.7% (cohabiting), 11.9% (romantically involved but not living together); and, among the fathers who were described as ‘not involved’ with the mother 19.9% were depressed (Huang & Warner, 2005).

4. The impact of fathers’ depression on infants and children

There is now clear evidence that fathers’ perinatal depression can impact negatively on their children.
• A substantial, UK/US study, which controlled for mothers’ depression and for fathers’ education levels, found severe postnatal depression in fathers associated with high levels of emotional and behavioural problems in their children (particularly boys) at age 3.5 years (Ramchandani et al, 2005) and at age 7 (Ramchandani & Stein, 2008).

• Some of the worst effects were found when the fathers were depressed both pre- and post-natally. Pre-natal depression, when it existed on its own, had a lesser effect than post-natal depression (Ramchandani et al, 2008).

• A pilot study to assess the relationship between paternal mood and infant temperament found higher paternal depression scores, more traditional attitudes towards fathering and increased recent life events related to higher infant fussiness scores (Dave et al, 2005).

The mechanisms through which negative impact on babies and children operate are not fully understood. Both direct and indirect effects seem likely. For example:

• Fathers’ depression puts at risk the quality of the relationship between the parents (Phares, 1997); and better couple relationship quality has been linked to lower infant fussiness scores (Dave et al, 2005). It is known that marital conflict and parental depression are causally related and connected with elevated adjustment problems in children, but relatively little is known about fathers’ depressive symptomology, marital conflict, and child development (Cummings et al, 2010)

• In the US, a study of Head Start families found that fathers with higher levels of depression had less involvement with their children (Roggman et al, 2002).

• A 3-year study of first-time fathers in Australia found stress negatively affecting fathers’ attachments to their infants (Buist et al, 2003). Poor father-child attachment has been linked, among other things, to problems in children’s peer relationships (for review, see Lamb & Lewis, 2010)

• While high psychological well being in fathers has been found to be positively associated with their sensitivity as parents (Broom, 1994) fathers’ depression (like mothers’) seems to limit their ability to parent effectively (Huang & Warner, 2005). For example:

* Preliminary results from an Oxford-based study suggest a higher proportion of infant-directed negativity in the way depressed fathers talk about, and to, their infants (Sethna et al, 2009)
* Depressed fathers are less likely to read, sing songs and tell stories to their babies than other fathers – and than depressed mothers (Paulson et al, 2006), which may explain why fathers’ depression has a more powerful negative impact than mothers’ depression on their infants’ language development in the first year.
* Depressed fathers use a flatter tone of voice in interactions with four-month-olds (Wanless et al, 2008) and this is linked with their infants’ cognitive delay.
* A recent meta-analysis that examined the effects of fathers’ depression more widely (i.e. not just in the perinatal period) on their parenting behaviours found a small though significant negative effect: decreased positive emotions, warmth, sensitivity and responsiveness, and increased negative emotions, hostility, intrusiveness and disengagement (Wilson & Durbin, 2010). As most of the fathers studied exhibited relatively mild depressive symptoms, it is likely that greater effects would be found with more serious depression.
* Some researchers have found fathers’ depression impacting more negatively on their parenting behaviours than mothers’.depression (Wilson & Durbin, 2010), leading others to speculate that this may often be often the case (Cummings et al, 2010), given that father-child interactions tend to be more negatively impacted than mother-child interaction by family stressors.

• Long-term negative impact on children of fathers’ depression may, as with depressed mothers, relate to chronicity: i.e. depressed new parents may continue to be depressed or function negatively in some manner in the longer term (Ramchandani et al, 2008), an hypothesis supported by Cox et al (1987) who found adverse mother-child interaction patterns continuing beyond the period of depression.

• There may be some exposure to genetic risk but this has not yet been demonstrated (Ramchandani et al, 2008).

• Either or both these factors may be relevant to the finding that pre-natal depressive symptoms in fathers are related to excessive infant crying (‘colic’), although in this study postnatal depression in the fathers was not measured (van den Berg et al, 2009).

• When both parents are depressed they are least likely to follow good-health guidelines with their babies – e.g. putting them to sleep on their back, breastfeeding, not putting them to bed with a bottle (Paulson et al, 2006).

• By contrast, Field et al (1999) reported that depressed fathers did not interact with their infants more negatively than non-depressed fathers; and McElwain & Volling (1999) found depressed fathers less intrusive than non-depressed fathers when observed playing with their 12-month-old. This however may have been symptomatic of disengagement, rather than less intrusive parenting (Wilson & Durbin, 2010).

5. Ameliorating the impact of mothers’ depression on infants: ‘father-as-buffer’?

When, and how, does fathers’ behaviour ‘buffer’ negative effects of mothers’ depression?

• Fathers’ support has been found to shield the infants of chronically depressed mothers from negative outcomes (Field, 1998), reducing mothers’ parenting stress (Jackson, 1999) and minimizing power-assertive maternal child-reading attitudes (Brunelli et al, 1995).

• Fathers have been found to have unusually high amounts of interaction with insecure-avoidant infant girls – the group with whom mothers interact least of all (Fagot & Kavenagh, 1993).

• A small (n: 25 families) observational study found that in most families where mothers suffered from persistent depressive mood, their infants had established joyful relationships with their fathers, and infant-father attachments were secure (Edhborg et al, 2003). Similar findings are reported by Hossain et al (1994).

• Infants of chronically depressed mothers have been found to learn in response to fathers’ (but not mothers’ or other women’s) infant-directed speech (Kaplan et al, 2004).

• Where new mothers are depressed, fathers’ positive parenting (self-reported) plus substantial time spent in caring for his infant, was found to moderate the long-term negative effects of the mothers’ depression on the child’s depressed/anxious mood – but not on their aggression and other ‘externalising’ behaviours (Mezulis et al, 2004).

But on the other hand . . .

• Goodman (2008) found the partners of depressed women demonstrating less optimal interaction with their infants (due, it seemed, to their own increased levels of depression and parenting stress), indicating that many fathers do not in the normal course of events compensate for the negative effects of maternal depression on the child. Interestingly, mother–infant interaction did not influence father–infant interaction: what seemed most influential was how the mother felt about her relationship with the infant. This had an even more significant impact on the father-child interactions than her actual depression.

• When both parents are depressed and the depressed father spends medium/high amounts of time caring for his infant, his depression can exacerbate the negative effects of mothers’ depression (Mezulis et al, 2004).

However, evidence that overall fathers can (and often do) ‘buffer’ their children against the worst effects of their mothers’ depression is found from a study that measured what happened when the fathers didn’t provide support:

• Where mothers had been depressed AND the fathers had worked long hours (particularly at weekends) in the first two years of their baby’s life, this predicted poor developmental outcomes for their child through to age 10, especially among boys (Letourneau et al, 2009).

Finally, evidence of the importance of fathers in buffering children from maternal depression is found from interviews with children:

• A study that followed a large group of U.S. children over 10 years, found that although mothers’ depression was related to escalating child behavior problems, this was not the case among children who said their fathers were highly involved in their lives (Chang et al, 2007).

• Women who, as children, experienced maternal rejection and/or had a mother who experienced depressive symptoms are at elevated risk of developing depression in the post-natal period. However, if their relationship with their father is remembered as positive and ‘accepting’: then they are much less likely to develop depressive symptoms postnatally (Crockenberg & Leerkes, 2003).

6. Interventions

A shorter length of hospital stay among women with pre/postpartal psychiatric disorders is strongly and positively correlated with supportiveness by their (male) partners. However, only 30% of these men are categorized by the researchers as supportive (Grube, 2004). In many cases, this will be due to their own depression and parenting stress (Roberts et al, 2006).

How, then, can fathers helped to support their partners and infants when the mothers are depressed – and deal with their own mobidity? A fair amount can happen at the family-level:

• Family members, including fathers, need to be educated about postnatal depression in women so they can recognise the symptoms and seek help (Dennis, 2009). The same applies to fathers’ own depression: both mothers and fathers need to be trained to recognize the signs and seek help.

• Fathers who feel supported by their partners in finding their own ways of caring for their infants are likely to develop a strong connection to their babies, and are also unlikely to develop depression (Cowan & Cowan, 1988).

Few interventions by professionals have been rigorously evaluated, and sample sizes are small. However, indications are positive – and some researchers (e.g. Roberts et al, 2006) suggest that the common failure of interventions with depressed mothers to produce positive, sustained results may in part be due to failure to engage with the fathers.

• The mental health of expectant and new fathers should be routinely assessed alongside mothers’. Where a mother is depressed or has developed a serious disturbance, assessment of her partner’s mental health and general wellbeing is particularly important (Holopainen, 2002; Howard et al, 2004, 2003).

• As early as the 1960s, Gordon & Gordon (cited by Brockingon, 2004) found that involving the babies’ fathers in a two-session ante-natal intervention that addressed the realities of postnatal experience, was more effective in preventing postpartum ‘emotional upsets’than just working with the mothers

• More recently, a randomized controlled trial in Canada found that where depressed women’s partners participated in 4 out of 7 psycho-educational visits, the women displayed a significant decrease in depressive symptoms and other psychiatric conditions. Interestingly, when only the women (and not their partners) received the intervention the general health of the depressed women’s partners deteriorated. This effect was not found where the men were included in the intervention (Misri et al, 2000).

• A brief, inexpensive US intervention (one prenatal session, in separate gender groups focusing on psychosocial issues related to becoming first-time parents) was associated with reduced distress in the neediest mothers at six weeks postpartum. The key factor seemed to be their perception of an increased level of awareness in the men as to how they were experiencing the early postpartum weeks. These mothers also reported greater satisfaction with the sharing of home/baby tasks. No effects were found for the men (Matthey et al, 2004).

• A controlled trial of a brief (one postpartum session) group intervention with mothers and fathers, addressing infant behaviour and couple-relationship management, found dramatically lower instances of depression/anxiety among women who had attended the couples-group-session than among those who had met with a health visitor at home (Fisher et al, 2010).

• In a case study of home-visiting support directed to the father in a couple in which the mother had been treated for depression after the birth, positive effects on father-infant interactions were observed with ‘knock-on’ positive effects on the mother’s parenting (Fletcher, 2009).

• A Randomised Controlled Trial in which depressed pregnant women received twice weekly massage therapy from their partners found those who received the massage reporting less depressed mood, anxiety and anger and better relationship quality than women in the control group (Field et al, 2008).

• In Norway (2005-6) two 8-session courses for ten men, all of whom were the partners of women being treated for pre or postnatal depression were organised through the clinic the mothers were attending, with strong support from clinic professionals and mothers. Over 80% of the men offered the intervention attended; and drop out was minimal (8/10 men completed the first course; 9/10 the second). The men evaluated the experience very highly; and anecdotal evidence from the clinic professionals identified benefits to the women (Reform, 2010).

• An outstanding US website supports men whose partners are depressed to provide effective support: http://postpartumdads.wordpress.com/information-for-partners/ – although usage has not been evaluated.

Early Years Services often succeed in engaging fathers (particularly young fathers) via sports. Generally this tactic is regarded as a ‘hook’ activity to draw the men into involvement with other services (Fathers Direct, 2002-06). In fact, involving fathers in sports activities should perhaps be considered an end in itself, not least because of the potential of regular aerobic exercise for improving mood.

While participation in a fathers’ group has been found to assist men in coping with their partner’s depression (Reform, 2010; Davey et al, 2006), group interventions may suit only particular types of fathers (Ghate et al, 2000) and in most areas it is not a priority to run groups for men whose partners are depressed. While the pilot groups for Norwegian fathers referred to above were enormously successful they have not been rolled out (Reform, 2010).

A number of ‘tools’ have been developed to assess expectant and new fathers’ mental health (Madsen & Burgess, 2010; Surrey Parenting Education & Support & the Fatherhood Institute, 2009). Routinely assessing men’s mental health in the perinatal period would lead to identification of treatable problems that would otherwise go undetected – benefiting not only the fathers but the mothers, too, given that ‘healthy’ men are likely to provide better care and support (Roberts et al, 2006).

When engaging fathers in support of depressed mothers and their children, a tactful approach may be needed: where new mothers’ feelings of autonomy are low (Grossman et al, 1988) or they are depressed or lack confidence as mothers (Lupton & Barclay, 1997) some may actively exclude fathers, and the fathers may sometimes hang back, fearing their interference could exacerbate the situation (Lupton & Barclay, 1997; Lewis, 1986). Nevertheless the importance of assessing men’s own mental health in the perinatal period and encouraging them to support their partners and children remains.

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2 Comments »

  • Laura says:

    I am currently training to become a midwife and I am looking into the role fathers play throughout pregnancy and the transition to parenthood as I have seen this to be a gap in maternity services. Through reading this it is clear that something needs to be done to meet the need of fathers, as they are a valuable support for women and have their own needs which need catering for.

    I really enjoyed reading this and hope to see and be a part of making positive changes to address the issues raised.

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