Postpartum depression in fathers

EVIDENCE- BASED CARE SHEET

ICD-9 648.4

ICD-10 F53.0

Authors Gilberto Cabrera, MD

Cinahl Information Systems, Glendale, CA

Orna Avital, RN, BSN, MBA Cinahl Information Systems, Glendale, CA

Reviewers Kathleen Walsh, RN, MSN, CCRN

Cinahl Information Systems, Glendale, CA

Sara Richards, MSN, RN Cinahl Information Systems, Glendale, CA

Nursing Executive Practice Council Glendale Adventist Medical Center,

Glendale, CA

Editor Diane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA

May 11, 2018

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Postpartum Depression in Fathers

What We Know › Although the incidence of postpartum depression (PPD) is lower in new fathers than in

new mothers, it remains a significant problem in men. The global incidence of paternal PPD is about 5–10%, and 15–20% of maternal PPD in western countries.(5,6,9,13) (For information about PPD, see Quick Lesson About … Postpartum Depression )

› The highest rates of depression among fathers have been reported to be 10.4% at the beginning of the first trimester of pregnancy, with an increase to approximately 25% 3–6 months postpartum.(13) The risk for paternal PPD is highest in fathers whose wives have developed PPD.(13) Other factors that increase the risk of paternal PPD include(6,7,8,13,14)

• a personal history of depression and/or anxiety • maternal depression during pregnancy • childhood experiences associated with negative attitude towards pregnancy • lower socioeconomic status • low education level • older age • low level of marital satisfaction, excessive financial/life stressors, and/or lack of paternal

parental leave • believing that there is a great discrepancy between personal expectations of parenthood

and the realities of parenthood – Family routine may change in unexpected ways and become unpredictable, leading the

father to perceive that the infant creates an unreasonable demand on time and energy – Planned pregnancies that are timed to suit the couple’s lifestyle preferences can create

unrealistic expectations – Fathers may feel as if they have completely lost their prepartum identity

• impaired paternal/newborn bonding and/or feelings of exclusion from maternal/newborn bonding

• perfectionist or neurotic personality traits • unplanned pregnancy • lack of social support for parenting • poor social functioning • dissatisfaction with partner support, communication, or adaptation • dissatisfaction with their partner due to unfavorable comparison of their partner with

their own mother, who may be viewed as tireless and capable • the presence of stepchildren or having a “blended” family

› Although there is no official set of diagnostic criteria for paternal PPD, it has been assessed by using the criteria for diagnosing maternal PPD(5,8,13)

• According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), maternal PPD is defined as a major depressive episode with onset within 4 weeks of delivery. Signs and symptoms of maternal PPD include(1,7,10)

– depressed or sad mood – marked loss of interest in usual activities – weight loss or gain – insomnia or hypersomnia

– psychomotor disturbances (e.g., incoordination, agitation) – fatigue – feelings of worthlessness, guilt, or inadequacy – diminished capacity to concentrate – suicidal ideation

• PPD signs and symptoms that are unique to men include(2,4)

– indecision – irritability and impulsivity – externalizing behavior (e.g., physical aggression, verbal bullying) – substance abuse

• Paternal PPD is often underdiagnosed because for reasons that are unclear, signs and symptoms of PPD develop more gradually in men than they do in women, and men are more likely to exhibit emotional distress through destructive behaviors and by exhibiting signs and symptoms of anxiety, which increases the risk of developing depression(7,11,13)

• Healthcare workers can identify PPD in fathers by observing for – anxiety demonstrated by the expression of feelings of fear, confusion, uncertainty about the future, concern about infant

care skills, disrupted family and social activities, and financial problems(5,7)

– cigarette smoking before, during, and after pregnancy, which is linked to a higher risk of developing PPD(12)

› Paternal PPD and resulting marital and parenting stress increase infant risk for the development of emotional and behavioral problems(3,5,6,13)

• Paternal PPD has a negative effect on the provision of typical child enrichment/positive interaction activity (e.g., telling stories, singing songs, and reading to the infant). An even greater negative effect on emotional and behavioral development is incurred if both parents develop PPD(3,5,6,8)

• Paternal PPD is more likely than maternal PPD to result in a significant impairment in the infant’s emotional and attachment development, and in impaired cognitive function(3,6)

• Children of fathers with PPD are more likely to demonstrate adverse outcomes by up to 7years of age compared with other children (e.g., learning difficulties, poor social skills), and an increased risk for depression in adolescence(6,7)

• For reasons that are unclear, the negative effect of paternal PPD is greatest in male children(6)

› Treatment for paternal PPD with family therapy is reported to(5,6,13)

• prevent and/or reduce paternal signs and symptoms of depressed or anxious mood • assist with development of an optimal parent-infant relationship • enhance positive child development • enhance the marital relationship • psychotherapy (e.g., mindfulness-based therapy [acceptance and commitment therapy]), as appropriate

What We Can Do › Become knowledgeable about PPD in fathers so you can accurately assess your patients’ personal characteristics and health

education needs; share this information with your colleagues › Educate patients who are expectant parents about what to expect after the baby is born, including the lack of personal time,

potential mood changes, and the possibility of feeling a lack of control over the newborn’s routines and demands • Provide written information, if available, to reinforce verbal education so parents can review it after the baby’s birth when

they are usually more focused on the specifics of childcare and more prepared to consider competing influences › Encourage patients who are new parents to discuss their expectations, coping skills, and life changes since the birth of the

baby; request screening for paternal PPD in families where the mother has developed PPD(8,13,14)

› Assist your patients in exploring extended family and other new baby support options; request referral to a social worker for identification of local resources for in-home services, community care resources, and support groups for new parents

› Request referral to a mental health clinician who specializes in family/marital therapy, if appropriate › Collaborate with your facility’s department of continuing education to provide information to pediatric clinicians regarding

the signs and symptoms of paternal PPD

Coding Matrix References are rated using the following codes, listed in order of strength:

M Published meta-analysis

SR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial)

C Case histories, case studies

G Published guidelines

RV Published review of the literature

RU Published research utilization report

QI Published quality improvement report

L Legislation

PGR Published government report

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions

GI General or background information/texts/reports

U Unpublished research, reviews, poster presentations or other such materials

CP Conference proceedings, abstracts, presentation

References 1. American Psychiatric Association. (2013). Panic disorder. In Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed., pp. 481-589). Washington, DC: American

Psychiatric Publishing. (GI)

2. Biebel, K., & Alikhan, S. (2016). Paternal postpartum depression. Journal of Parent and Family Mental Health, 1(1), 1-5. doi:10.7191/parentandfamily.1000 (RV)

3. Cheng, E. R., Kotelchuck, M., Gerstein, E. D., Taveras, E. M., & Poehlmann-Tynan, J. (2016). Postnatal depressive symptoms among mothers and fathers of infants born preterm: Prevalence and impacts on children’s early cognitive function. Journal of Developmental & Behavioral Pediatrics, 37(1), 33-42. doi:10.1097/DBP.0000000000000233 (R)

4. Fisher, S. D. (2016). Paternal mental health: Why is it relevant? American Journal of Lifestyle Medicine, 11(3), 200-211. doi:10.1177/1559827616629895 (RV)

5. Fisher, S. D., & Garfield, C. (2016). Opportunities to detect and manage perinatal depression in men. American Family Physician, 93(10), 824-825. (RV)

6. Høifødt, R. S., Nordahl, D., Pfuhl, G., Landsem, I. P., Thimm, J. C., Ilstad, L. K. K., ... Arfwedson Wang, C. E. (2017). Protocol for the northern babies longitudinal study: Predicting postpartum depression and improving parent-infant interaction with the newborn behavioral observation. BMJ Open, 7(9), 1-10. doi:10.1136/bmjopen-2017-016005 (R)

7. Kumar, S. V., Oliffe, J. L., & Kelly, M. T. (2018). Promoting postpartum mental health in fathers: Recommendations for nurse practitioners. American Journal of Men’s Health, 12(2), 221-228. doi:10.1177/1557988317744712 (RV)

8. Langan, R. C., & Goodbred, A. J. (2016). Identification and management of peripartum depression. American Family Physician, 93(10), 852-858. (RV)

9. Massoudi, P., Hwang, C. P., & Wickberg, B. (2016). Fathers’ depressive symptoms in the postnatal period: Prevalence and correlates in a population-based Swedish study. Scandinavian Journal of Public Health, 44(7), 688-694. doi:10.1177/1403494816661652 (R)

10. Parekh, R. (2017, March). What is postpartum depression? Depression during pregnancy and after childbirth. American Psychiatric Association. Retrieved April 26, 2018, from http://psychiatry.org/patients-families/postpartum-depression/what-is-postpartum-deression (RV)

11. Philpott, L. F. (2016). Paternal postnatal depression: How midwives can support families. British Journal of Midwifery, 24(7), 1-3. doi:10.12968/bjom.2016.24.7.470 (RV)

12. Swanson, E., Scott, E., & Thomas, M. (2017). Smoking and its effects on postpartum depression. Advances in Pharmacy: Journal of Student Solutions to Pharmacy Challenges, 1(1), 1-9. (R)

13. Vismara, L., Rolle, L., Agostini, F., Sechi, C., Fenaroli, V., Molgora, S., ... Tambelli, R. (2016). Perinatal parenting stress, anxiety, and depression outcomes in first-time mothers and fathers: A 3- to 6-months postpartum follow-up study. Frontiers in Psychology, 7(938), 1-10. doi:10.3389/fpsyg.2016.00938 (R)

14. Zhang, Y. P., Zhang, L. L., Wei, H. H., Zhang, Y., Zhang, C. L., & Porr, C. (2016). Post partum depression and the psychosocial predictors in first-time fathers from northwestern China. Midwifery, 35, 47-52. doi:10.1016/j.midw.2016.01.005 (R)