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postpartum_depression.pdf

Identifying the support needs of fathers affected by post-partum depression: a pilot study N . L E T O U R N E A U 1 , 2 , 3 p h d r n , L . D U F F E T T - L E G E R 4 , 5 p h d ( c ) r n , C . - L . D E N N I S 6 , 7 p h d , M . S T E W A R T 8 , 9 p h d f r s c f c a h s & P . D . T R Y P H O N O P O U L O S 1 0 b n r n p h d s t u d e n t 1Canada Research Chair in Healthy Child Development, 2Professor, 4CIHR Allied Health Professional Doctoral Fellow, 5Research Associate, 10Project Director, Faculty of Nursing, and 3Research Fellow, Canadian Research Institute for Social Policy, University of New Brunswick, Fredericton, NB, and 6Canada Research Chair in Perinatal Community Health, 7Associate Professor in Nursing and Psychiatry, University of Toronto, Toronto, ON, and 8Health Senior Scholar, Alberta Heritage Foundation for Medical Research, and 9Professor, Faculty of Nursing and School of Public Health, University of Alberta, Edmonton, AB, Canada

Keywords: barriers to accessing

support, fathers, men’s mental health,

men’s support needs, pilot study, post-

partum depression

Correspondence:

N. Letourneau

University of New Brunswick

PO Box 4400

Fredericton

NB E3B 5A3

Canada

E-mail: [email protected]

Accepted for publication: 9 August

2010

doi: 10.1111/j.1365-2850.2010.01627.x

Accessible summary

• The purpose of this pilot study was to describe the experiences, support needs, resources, and barriers to support for fathers whose partners had experienced post-partum depression (PPD).

• Telephone interviews were conducted with a total of 11 fathers. We interviewed seven fathers from New Brunswick and four fathers from Alberta.

• The fathers we spoke with experienced a number of depressive symptoms including: anxiety, lack of time and energy, irritability, feeling sad or down, changes in appetite, and thoughts of harm to self or baby. The most common barriers to accessing support included not knowing where to look for PPD resources and difficulty reaching out to others.

• This study demonstrated the feasibility of a larger-scale exploration of fathers’ experiences in supporting their spouses affected by PPD.

Abstract

The purpose of this pilot study was to describe the experiences, support needs, resources, and barriers to support for fathers whose partners had post-partum depres- sion (PPD) in preparation for a larger study. Qualitative methods and community- based research approaches were used in this exploratory/descriptive multi-site study, conducted in New Brunswick and Alberta. Telephone interviews were conducted with a total of 11 fathers in New Brunswick (n = 7) and Alberta (n = 4). Fathers experienced a number of depressive symptoms including: anxiety, lack of time and energy, irrita- bility, feeling sad or down, changes in appetite, and thoughts of harm to self or baby. The most common barriers for fathers were lack of information regarding PPD resources and difficulty seeking support. This pilot study establishes the feasibility of the larger-scale exploration of fathers’ experiences in supporting their spouses affected by PPD.

Note: There are no conflicts-of-interest or financial disclosure arrangements.

Journal of Psychiatric and Mental Health Nursing, 2011, 18, 41–47

Introduction

Post-partum mood disorders represent the most frequent form of maternal morbidity following delivery (Stocky & Lynch 2000, Gaynes et al. 2005). Post-partum depression (PPD) is a major health problem for many women, charac- terized by the disabling symptoms of dysphoria, emotional lability, insomnia, confusion, significant anxiety, guilt, and suicidal ideation. Frequently exacerbating these indicators are low self-esteem, inability to cope, feelings of incompe- tence and loss of self, and loneliness (Beck 1992, Mills et al. 1995, Righetti-Veltema et al. 1998, Ritter et al. 2000) A meta-analysis of 59 studies reported an overall prevalence of major PPD to be 13% (O’Hara & Swain 1996). Extrapo- lating from Statistics Canada birth rate data, as many as 50 000 Canadian women experience PPD every year (Statistics Canada 2010). The impact of maternal PPD on child development is well documented in the literature. Post-partum depression affects maternal–infant interaction quality, stresses infants, and produces adverse child social and cognitive developmental outcomes (Murray & Cooper 1996, 1997a,b,c, 1999, Murray et al. 1996, 1999, 2003).

While maternal PPD has been extensively studied in the last decade, much less is known about the impact of PPD on fathers. Goodman’s (2004b) meta-analysis revealed that between 24% and 50% of men whose partners have PPD also experience depression in the first year after birth. A more recent meta-analysis revealed a significant correlation between maternal and paternal depression (r = 0.31) and that 10% of new fathers experience PPD in community samples (Paulsen & Bazemore 2010). Symptoms of pater- nal depression typically appear with the onset of their partners’ PPD and the number and severity of symptoms increases during the first post-partum year. It is often the consequence of more severe maternal symptoms (Pinheiro et al. 2006) as well as decreased marital or relationship satisfaction (Dudley et al. 2001, Buist et al. 2002, Bielawska-Batorowicz & Kossakowska-Petrycka 2006), resulting in greater parenting stress (Goodman 2004b), paternal fatigue, and aggression (Roberts et al. 2006). Paternal substance abuse (Tannenbaum & Forehand 1994) and economic stress (Ram & Hou 2003) may further com- pound these problems. Children with two depressed parents are at significantly greater risk for poor develop- mental outcomes compared to those with one affected parent (Dierker et al. 1999, Brennan et al. 2002). Like mothers, the emotional well-being of fathers has been shown to have an impact on the father–infant interaction (Goodman 2004a) and may result in long-term behavioural problems in children (Ramchandani et al. 2005). The degree to which fathers are affected by their partners’ PPD merits exploration.

To date, no research has been found that explored fathers’ support needs for coping with PPD. The objectives of this pilot study were to describe the experiences, support needs, resources, barriers and preferences for support of fathers whose partners have had PPD. Stewart’s social support framework (1993) guided the study with its emphasis on understanding the pathway(s) between stress- ful events, coping and social support. The perceived avail- ability of social support in the face of a stressful event may lead to a more benign appraisal of the situation, thereby preventing a cascade of ensuing negative emotional and behavioural responses. Indeed, perceived or received support may either reduce the negative emotional or behav- ioural response to stressful events or expand the coping repertoire (Stewart 1993). Understanding how fathers per- ceive or receive support when their partners suffer from PPD may be useful to developing interventions to support the couple’s coping repertoire. Thus, specific research ques- tions included: (1) What are fathers’ experiences coping with PPD in their partners? (2) What are fathers’ experi- ences with personal PPD? (3) What demographic or descriptive variables may be associated with fathers’ nega- tive outcomes? (4) What are fathers’ support needs? (5) What are fathers’ support resources? (6) What barriers do fathers encounter in supporting their partners with PPD? and (7) What support interventions do fathers prefer for themselves and their partners?

Method

Research design and analysis

After receiving ethical approval for this qualitative pilot study from the appropriate institutional review boards, one-on-one interviews were conducted with male partners of women who have experienced PPD. Fathers were made aware of the legal requirement to report any disclosure of threat of harm to a child or another adult prior to being interviewed. The research team included skilled mental health nurses and social workers who were available to provide counselling, support and service referral to fathers if required.

A pilot study was selected for several reasons. First, while beginning research suggests that the telephone may be a useful means to engage fathers in research (Kirsch & Brandt 2002, Phares et al. 2005), it was uncertain how effective this method would be for qualitative research with this population. Second, while the interview guide had been successfully used with mothers in previous research (Letourneau et al. 2007) we wanted to adapt and thor- oughly pilot the interview to ensure sensitivity to fathers. Third, a pilot study was an essential first step to gain the

N. Letourneau et al.

information needed to develop a supportive intervention tailored to meet their needs. Finally, consistent with community-based research methods (Hills & Mullett 2000, Seifer & Vaughn 2004, Shallwani & Mohammed 2007), the pilot study provided the time and opportunity to develop an advisory committee comprised of mental health service providers and policy makers/influencers from across Canada that would be involved in both the pilot study and the larger follow-up study. Advisory committee members were regularly consulted regarding the feasibility of methods, recruitment strategies and results.

Telephone interviews, lasting from one to 2 h in dura- tion, were successfully conducted in locations of fathers’ choice, such as a community centre, participants’ homes, or another location. A semi-structured interview guide was utilized to collect demographic and exploratory data on fathers’ experiences, support needs and resources, barriers encountered in accessing, support and support intervention preferences. The interview guide consisted of questions gathering demographic information, followed by 27 ques- tions and suitable probes addressing the seven research questions. The questions were acceptable to fathers as they were able to answer them with little need for clarification. Individual interviews were audio taped and transcribed verbatim. Thematic content analysis was used to answer the primary research questions. The coding framework was created iteratively by at least two team members having read two to four transcripts each. After reading assigned transcripts, an open coding process was used by individual team members to categorize the data. The team members then met and integrated their respective coding frameworks into an all-encompassing framework. The integrated coding framework was revised again after additional tran- scripts were read; revision occurred until the team felt the framework was sufficiently comprehensive and complete. Two trained research assistants then coded the data using the coding framework. An acceptable inter-rater reliability of 77% was achieved by having coders individually code the same interview transcripts and assessing the degree of agreement in assignment of text segments to framework codes.

Setting and sample

Fathers were selected in two study sites, one where exten- sive services were available for PPD [Calgary, Alberta (AB)] and the other where fewer services were available [rural region of New Brunswick (NB)]. Convenience sampling was employed to recruit men whose partners reported symptoms of PPD during their last pregnancy and were no more than 24 months post-partum. This upper limit was selected to maximize fathers’ recall. Participants were

recruited via posters strategically placed in community partners’ agencies, by self-nomination or by service pro- vider nomination. The sample of 11 men included four from the Calgary, AB and seven from NB. Selecting partici- pants from two different provinces with different available PPD services provided an opportunity to examine this potential influence on participants’ perspectives of support needs, available resources, barriers to support, and pre- ferred interventions.

Findings

Demographic data provides a profile of the fathers from NB and AB. Qualitative data describe the support needs, resources, barriers to support, and preferences for support from the perspectives of the majority of sampled fathers affected by PPD. Exemplar quotes are highlighted that illustrate the qualitative findings.

Description of participants

A total of 11 fathers were interviewed in NB (n = 7) and AB (n = 4). The mean age of fathers was 37, with ages ranging from 29 to 44. All fathers reported being born in Canada with English as their first language. Ten fathers were married at the time of interview while one father was single. All 11 fathers were employed full-time, and most were graduates of a technical school (n = 3), college or university undergraduate degree (n = 3) or graduate (n = 3) programme. A majority reported household incomes greater than $70 000. For many of these fathers (n = 6), their partners had only one pregnancy, and two of the fathers reported that they had lost a child within the first year of life.

Fathers’ experiences coping with partners’ PPD

All the fathers interviewed described a wide range of emotions when their partners were experiencing PPD, and three fathers actually identified themselves as being depressed. Some revealed that they had experienced a variety of depressive symptoms, including anxiety, sleep disturbances, fatigue, irritability, sadness, changes in appetite, and thoughts of bringing harm to self or baby. Fathers described feelings of self doubt, helplessness and worry about their inability to help their partners. For example,

I thought I was doing a good job, and suddenly here it is and I’m going is it something that I didn’t do or did too much of? So there’s a lot of that self-doubt for sure (DAD_02).

Support for fathers affected by post-partum depression

I think throughout the experience I had more or less the feeling of like I wasn’t able to help her just because I wasn’t – I couldn’t – I didn’t really understand why she couldn’t sleep so and didn’t understand how bad her anxiety was . . . and then if you’re worried about your partner as well, that can be quite stressful (DAD_06).

Other fathers expressed feelings of anger, frustration and even rage, often in response to their lack of preparation for the possibility of PPD in their lives. As one father said, fathers learn the hard way that ‘it’s not just freaky people unbalanced to begin with who might feel this’ (DAD_08). He went on to say:

But if people don’t talk a little bit about it and don’t say look I’m a normal guy and I love my kid, but her crying was just driving me nuts. Which is stupid because really the feeling inside is you want to protect her and make her feel better, but at the same time what is coming up is holy cow, I’ve just got to shut her up (DAD_08).

Fathers also expressed fear or worry for their partners and relationship uncertainty. For example,

In terms of anxiety, certainly some anxiety because we would actually just walk around the house on eggshells wondering if (wife) is going to have one of these epi- sodes and what is the effect going to be on her and on our little guy (DAD_10).

They attributed their feelings to a variety of factors including infants’ health issues, interference by extended family, a recent move, and employment or financial stress. The reduced income associated with maternity leave and the extra expenses associated with a new child were regarded as stressful for some. Other fathers spoke about their loss of freedom associated with the demands of new parenthood and marital conflict as contributors to their negative feelings.

Just not being able to pick up and go golfing or you know, go out and shoot pool or whatever with a friend or you know and I think that’s where the stress was . . . and still sometimes I’d like to go out for a movie but then you’ve got the kids to look after and the babysitters and the money and all that stuff (DAD_07).

Some fathers described escaping through work as a coping mechanism. But many recognized that this was a special privilege that only one of them (mother or father) could use to advantage. As one father said ‘I was getting on the freedom bus everyday. So what changed in my life? Well not nearly the same degree of change that (wife) was seeing’ (DAD_02). Others indicated that work prevented them from becoming depressed themselves. Other coping behaviours included: staying active, getting exercise, getting out of the house, and self isolation or avoidance of social situations. One father spoke about getting ‘out

and going for a run’ and needing to ‘just get out and separate myself’ (DAD_05) from their partners and situation.

Another common experience was fathers’ inability to interpret what was wrong with their partners, attributing their behaviours to being a first-time mother or having a new baby in the home. Thus, some fathers spoke of mini- mizing their partner’s symptoms by attributing her mood changes to the stress of having a new baby. While a number of fathers detected changes in partners’ emotional status, they did not initially identify it as PPD. Most fathers believed that their partners needed professional help; however, nearly half were unaware that there was some- thing ‘wrong’ with their partners until after she had returned to her ‘old self’. As one father said after his partner’s PPD was resolved:

I didn’t know what I was looking for. I didn’t recognize there was as much of a problem as there actually was (DAD_09).

Support needs and resources of fathers and mothers

Fathers reported numerous support needs for themselves and their partners. Accessing information about PPD and professional health services for their partners was identified as important. Having someone who would listen was espe- cially important to fathers whether for themselves or their partners. As one father said, he relied on his ‘handful of friends’ with whom he ‘felt comfortable talking about it (PPD)’ (DAD_01). For many fathers, gaining friends’ insight into how they coped with similar experiences was deemed helpful. Other fathers spoke about how finding help from friends or professionals helped them both. For example,

Just to meet people who were saying, yep I was bad. And your situation was nothing like mine and mine is nothing like yours but I made it. Whenever she could find one of those people it was like hallelujah day (DAD_04). And she was on that unit and it was the best thing that could have happened cause, it was so much easier for me, because I’m obviously not trained to deal with that kind of stuff (DAD_05).

Most fathers tried to be self-reliant, describing different strategies for identifying PPD resources for their partners: the most common of which was ‘digging for information’. All the fathers reported an information gap regarding PPD resources that contributed to the lack of recognition and early detection of PPD. As one father said, ‘somebody should be there talking about this we shouldn’t wait until it happens and then have an intervention, should be preven- tion’ (DAD_01). This lack of awareness was followed by

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not knowing where to look for resources, reported by all but one father. Three of the 11 fathers reported that family and friends were their most significant sources of support. Unfortunately, many participants reported that their family and friends had limited understanding of PPD or lived too distant to be helpful.

Barriers to support for fathers

All 11 fathers reported experiencing some form of barrier, which impeded their ability to get support for their part- ners and/or themselves. The most commonly reported barrier was lack of information regarding PPD resources, followed by not knowing where to look for resources, and fear of the stigma associated with PPD. As one father said:

I think just a lack of knowledge on the subject was probably the only thing that was probably the only stressful thing that was really bugging me at that time. It was just because of the confusion of what’s happening with my wife (DAD_06).

Fathers described their own lack of awareness and understanding. Many fathers ‘naively thought everything was okay’ (DAD_02). Others reported only knowing about the ‘absolutely horrible cases’ and that ‘anytime I heard about PPD, I kind of always associated it with Andrea Yates . . . the one that drowned her babies’ (DAD_07). Only later did the fathers learn that that the media example is ‘not even close to the actual experience’ (DAD_07).

On father commented on stigma linked to PPD: I’d be aware of it but would I be digging out the pam- phlet you know and checking off the points kind of thing . . . Unfortunately mental illness is still one of those things that is kept in the closet for a large degree. Unfortunately it is and people say oh I’d never judge people on something like that, but hey, I’d beg to differ (DAD_02).

Even when fathers overcame their feeling of stigma and determined that they needed help, they also often reported feeling too overwhelmed and exhausted to seek help. Fathers cited lack of time and energy, particularly for those caring for other children, as well as work commitments and transportation challenges. For example:

I had a lot of responsibility but I think because so much was going on I didn’t have the energy to seek out one person to find out more about this (DAD_09).

Moreover, when help was found, fathers talked about being ignored by health professionals. Some fathers accompanied their partners to treatment, and while they wanted to contribute to their partners’ care, health pro- fessionals excluded them from the treatment process. As

one father said, ‘the issue is about how the doctor spoke to (wife) and really didn’t include me in the conversation’ (DAD_10).

Several fathers reported that the stigma associated with PPD significantly contributed to their partners’ denial of the issue, which often proved to be another barrier to support. Fathers described their partners’ resistance to recognizing that they needed help. As one father said:

So it took awhile for her to be self aware and it also took awhile for her to get over the stigma and to realize this is serious enough that we had to do something. In terms of me personally, it would be just my own character flaws. Just really not being comfortable accepting help from anyone (DAD_06).

The last quote reflects an independence that was identi- fied by most fathers as an important barrier. As one father said ‘it’s like that strong, stoic guy thing’ (DAD_03). In spite of some fathers speaking about the value of help provided by friends and professionals, they admitted that they had difficulty reaching out to others and did not want to burden others with their problems.

I guess looking back now I think I could have used some support, somebody to talk to. Perhaps, like it’s a kind of a guy thing – I’m not going to really seek it out. I think most – a lot of guys are like that. I’m not going to . . . like I say, I’ll talk to my friends and that’s prob- ably as close as you’re going to go to opening up to somebody (DAD_09).

Further, some fathers cited personal difficulties under- standing or wanting to share their own feelings.

We’d definitely talk about it, especially in the presence of our wives, but from my standpoint, I would make jokes and laugh about it. It wouldn’t get into the deep, break down crying sessions with another guy about how much pressure it’s putting on you right now (DAD_03).

Societal views regarding parental-gender roles rein- forced many fathers’ attitudes and posed a barrier to support. While everyone asked the fathers about their partners and the baby, no one asked the fathers about how they were dealing with the transition to parenthood. As a result, some felt that they had no one to talk to about their own symptoms. These fathers appreciated it when others appeared interested in their well-being, as expressed by this man:

I think men and women have different experiences. It’s more accepting for women to share with her female friends about this stuff and men it’s not I don’t think, I mean it’s changing, but I still think a lot of men are of stuck in the idea that you can’t go out with your peers and seek information out, you’re in your own solitude to figure it out and hope to God you’ve got the resources (DAD_08).

Support for fathers affected by post-partum depression

Discussion

The findings of this pilot study describe a wide range of emotions experienced by fathers. Indeed, over a quarter of these fathers described a variety of depressive symptoms, consistent with other literature (Goodman 2004b, Pinheiro et al. 2006). Many fathers discussed feelings of anger, frus- tration and anxiety associated with their lack of understand- ing and helplessness to do anything about their partners’ PPD. Thus it is not surprising that PPD is known to negatively affect marital relationship quality (Bielawska- Batorowicz & Kossakowska-Petrycka 2006). Fathers spoke about both: (1) attributing PPD to stressors in adjusting to parenthood, and (2) the stress of PPD itself. Fathers identi- fied coping mechanisms associated with immersion in work and seeking time for themselves. Others misattributed or misidentified the symptoms of PPD as everyday reactions to financial and infant health concerns. In spite of the differ- ences in the availability of supports and services for PPD in the two study regions, very little difference was observed in the findings of fathers from the two regions. As this was a pilot study with a relatively homogeneous sample, cultural differences in fathers’ perspectives of support needs, resources, barriers and preferences were not examined; however, this could be the subject of future research.

Fathers reported needing support from both formal (professional) and informal (friends and family) support resources. However, a dominant theme suggested that both men’s and societal attitudes about gendered approaches to help-seeking roles challenged many men to find support for themselves or their partners. This finding is consistent with other research suggesting that men feel they should be reluctant to seek help (O’Brien et al. 2005). Fathers’ per- ceptions that insufficient social support would be available to them to help them cope with the stress of PPD may have, according to Stewart (1993), prevented them from more benign appraisals of their situations and from seeking help. Given that perceived or received support is believed to reduce the negative emotional or behavioural response to stressful events (Stewart 1993), it was not surprising that so many fathers experienced anger, frustration and anxiety in response to their partners’ PPD.

Although supportive fathers can protect their partners from a depressive relapse (Misri et al. 2000) and are fre- quently the source of support most relied on by mothers, their role and experience as support provider have not been well explored or utilized (Murray & Cooper 2003). Indeed, in previous research exploring the support needs of women with PPD, the women perceived their husbands as support- ive but restricted by their limited understanding of PPD and how to offer support (Letourneau et al. 2007). Many women recognized that their partners wanted to do more;

however, interventions for women with PPD have not focused on supporting fathers as they care for their part- ners affected by PPD. Moreover, men’s and societal atti- tudes toward help-seeking by fathers may impede the full utilization of innovative interventions (O’Brien et al. 2005). To date, best practices to help fathers support their partners affected by PPD are unknown.

For fathers who overcame stigma and gender roles, they faced other barriers to accessing support including diffi- culty identifying other sources of support, even in areas where services were available. Moreover, when support was found, fathers reported feeling excluded. These find- ings suggest that much work is needed to educate new parents about PPD, to normalize this highly stigmatizing mental health issue, and to include fathers in treatment planning for mothers affected by PPD.

This pilot study provided a preliminary investigation of fathers’ support needs, resources, and barriers to accessing support. In addition to contributing to our understanding of the impact of PPD on fathers, the pilot study provided the evidence necessary to support an expanded emphasis on obtaining participants’ views on preferred support inter- ventions in the follow-up study. Most importantly, this project provided a foundation for guiding the development of a supportive intervention for fathers and their partners affected by PPD.

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Support for fathers affected by post-partum depression

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