Duncan Fisher

Tradition: the sacred mother-baby bond. Joseph is there in the dark, top right if you look very carefully!

Last week was Mind’s Mental Health Week and it focussed on men.  And this week I am speaking at the Primary Care 2009 conference on postnatal depression and fathers.  (I am told my audience will be about 1000 people!)  Here is my full presentation, which is summarised below (references at end of blog).

Studies suggest about 10% of fathers suffer from postnatal depression (PND), a third of those severely.  This is about twice the average rate for men in the age group.  Correlates of PND in fathers include a history of severe depression, anxiety and depression antenatally, problems with the baby and - highly significantly - depression in the mother and a poor relationship with the mother.

Maternal depression is similarly correlated with a poor relationship with the father and depression in the mother.  In short, it would appear that parents are interdependent.  As one researcher put it, depression is “contagious”.

Depressed fathers interact less with their children and there is a significant correlation between PND in fathers and psychiatric disorders in children at 3.5 and 7 years.  Severe depression in fathers correlates with an 8-36x greater likelihood of a child having behaviour and peer problems.

Maternal depression has similar impacts on children, but interdependence reveals itself again: the negative impacts of maternal depression on a child are substantially worse if the father is depressed also.  It would appear that fathers in better mental health buffer the influence of mothers’ poor health.

This interdependence is found also in research on breastfeeding and smoking.  Together the evidence suggests that the father has a highly significant impact on maternal and child health.

Family health services are largely still based on the traditional belief that all that matters is the unique mother-child bond, with the father hovering indeterminately around the edge - as depicted in countless European representations of the Nativity, like the 15th century painting by Geertgen that I have included above.  Practice based on this model believes that the health and well-being of mother and baby can be achieved simply by engaging with the mother.  The evidence, however, presents a different picture - a system of influences where every individual and every relationship around a child impacts profoundly on every other individual and relationship. Only a systemic approach can deliver the desired health outcomes.

So the reason why maternity services need to engage with fathers is because this is necessary to support the health and well-being of mothers and babies - in other words, it is core business.  PND in fathers is not just the latest diverting curiosity of media discussion: it requires a change in health services.

Small trials of interventions with fathers have worked well.  One antenatal session for first-time parents together on mental health issues correlated with less distress in mothers six weeks after the birth.  A randomised control trial in Canada showed less depression in mothers where the fathers participated in four out of seven visits.  Interestingly in this study, paternal depression was greater for the fathers who were not included.  This evidence is reflected in rather more substantial trials of breastfeeding and smoking interventions.  In short, engaging with fathers works, and just by including fathers in existing services - it does not cost more.

NICE Clinical Guidance, Antenatal and postnatal mental health: clinical management and service guidance (2007) specifies that health professionals should “assess and, where appropriate address, the needs of the partners, family members and carers of a woman with a mental disorder during pregnancy and the postnatal period.”

The evidence suggests also that where mothers are depressed, it is important to support mental health in the father and positive father-child interaction.  This requires a proactive and tactful approach, given the tendency for mothers lacking confidence to exclude fathers and the tendency for fathers in this situation to hang back.

References

Areias ME, Kumar R, Barros H, Figueiredo E, Correlates of postnatal depression in mothers and fathers, Br J Psychiatry, 1996 Jul;169(1):36-41
Broom BL, Impact of marital quality and psychological well-being on parental sensitivity, Nursing Research, 1994;43:138-143
Buist A, Morse CA & Durkin S, Men’s adjustment to fatherhood: implications for obstetric health care, Journal of Obstetrics, Gynaecology & Neonatal Nursing, 2003;32:172-80
Cowan CP, Cowan PA, Heming G & Miller N, Becoming a family: marriage, parenting and child development. In Cowan PA & Hetherington EM (eds), Family Transitions: Advances in Family Research. 1991. Hillsdale, NJ: Lawrence Erlbaum
Dave S, Sherr L, Senior R, Nazareth I, Associations between paternal depression and behaviour problems in children of 4-6 years, Eur Child Adolesc Psychiatry, 2008 Aug;17(5):306-15
Dudley M, Roy K, Kelk N & Bernard D, Psychological correlates of depression in fathers and mothers in the first postnatal year, Journal of Reproductive and Infant Psychology, 2001;19(3):187-202
Dudley M, Roy KFisher JRW, Cabral de Mello M, Patel V & Rahman A, Maternal depression and newborn health. Newsletter for the Partnership of Maternal, Newborn & Child Health, 2006;2. Geneva. (Available at http://www.pmnch.org)
Gao LL, Chan SW, Mao Q, Depression, perceived stress, and social support among first-time Chinese mothers and fathers in the postpartum period, Res Nurs Health, 2009 Feb;32(1):50-8
Goodman JH, Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health, J Adv Nurs, 2004 Jan;45(1):26-35
Grube M, Pre- and postpartal psychiatric disorders and support from male partners. A first qualitative approximation. Nervenarzt, 2004;75(5):483-488, Kelk N & Bernard D, Psychological correlates of depression in fathers and mothers in the first postnatal year, Journal of Reproductive and Infant Psychology, 2001;19(3):187-202
Huang CC & Warner LA, Relationship characteristics & depression among fathers with newborns, Social Service Review, 2005; 79:95-118
Kahn RS, Brandt D, Whitaker RC, Combined effet of mothers’ and fathers’ mental health symptoms on children’s behavioural and emotional well-being, Arch Pediatr Adolesc Med, 2004 Aug;158(8):721-9
Kaplan PS, Dungan JK & Zinser MC, Infants of chronically depressed mothers learn in response to male, but not female, infant- directed speech, Developmental Psychology, 2004;40:140-148
Lewis C, Becoming a Father. 1986. Milton Keynes: Open University Press
Lupton D & Barclay L, Constructing Fatherhood: discourses and experiences. 1997. London: Sage Publications
Madsen SA, Fathers and postnatal depression: research results from the Project: Men’s Psychological Transition to Fatherhood: Mood Disorders in Men Becoming Fathers. Copenhagen: Rigshospitalet. Obtained from: svaam@rh.dk
Matthey S, Barnett B, Ungerer J, Waters B, Paternal and maternal depressed mood during the transition to parenthood, J Affect Disord, 2000 Nov;60(2):75-85
Matthey S, Kavanagh DJ, Howie P, Barnett B & Charles M, Prevention of postnatal distress or depression: an evaluation of an intervention at preparation for parenthood classes, Journal of Affective Disorders, 2004;79(1-3):113-26
Misri S, Kostaras X, Fox D & Kostaras D, The impact of partner support in the treatment of postpartum depression, Canadian Journal of Psychiatry, 2000;45(6):554-8
Morse CA, Buist A, Durkin S, First-time parenthood: influences on pre- and postnatal adjustment in fathers and mothers, J Psychosom Obstet Gynaecol, 2000 Jun;21(2):109-20
Paulson JF, Dauber S, Leiferman JA, Individual and combined effects of postpartum depression in mothers and fathers on parenting behaviour, Pediatrics, 2006 Aug;118(2):659-68
Perren A, von Wyl A, Burgin D, Simoni H, von Klitzing K, Depressive symptoms and psychosocial stress across the transition to parenthood: associations with parental psychopathology and child difficulty, J Psychosom Obstet Gynaecol, 2005 Sep;26(3):173-83
Ramchandani PG, O’Connor TG, Evans J, Heron J, Murray L, Stein A, The effects of pre- and postnatal depression in fathers: a natural experiment comparing the effects of exposure to depression in offspring, J Child Psychol Psychiatry, 2008 Oct;49(10):1069-78
Ramchandani PG, Stein A, Evans J, O’Connor TG, ALSPAC study team, Paternal depression in the postnatal period and child development: a prospective population study, Lancet, 2005 Jen 25-Jul 1;365(9478):2201-5
Ramchandani PG, Stein A, O’Connor TG, Heron J, Murray L, Evans J, Depression in men in the postnatal period and later child psychopathology: a population cohort study, J Am Acad Child Adolesc Psychiatry, 2008 Apr;47(4):390-8
Roggman LA, Boyce LK, Cook GA & Cook J, Getting dads involved: predictors of father involvement in early head start and with their children, Infant Mental Health Journal, 2002;23(1-2): 62-78

Fatherhood birth, Fatherhood, maternity, postnatal depression