Paternal Depression in New and Expectant Dads

Lena Green, DSW,LCSWApril 21, 2020

‣ New & Expectant Dads

Learning Objectives ‣ Gain an understanding about the concept of

paternal perinatal depression

‣ Increase knowledge regarding the risk factors related to paternal perinatal depression

‣ Understand the effects of paternal perinatal depression on children and families

Poll QuestionHow often do you assess mothers in the lives of the children you work with?

A. OftenB. SometimesC. RarelyD. Never

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Poll QuestionHow often do you assess fathers in the lives of the children you work with?

A. OftenB. SometimesC. RarelyD. Never

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Why Focus on Fathers?‣ The transition to parenthood represents an

important event in the life cycle resulting in increased vulnerability to psychological disorders as fathers adapt to widespread changes in roles, expectations and demands

‣ Families are complex systems that consist of individuals who relate to one another in unique but interdependent ways

‣ Fathers are an essential part of the family system and contribute to child development in significant ways

Why Focus on Fathers Continued

‣ Father bias must be addressed in the overall culture that often focuses solely on mothers, and presumes mothers are the more impactful parent

‣ Depression in new and expectant fathers is often overlooked by mental health professionals

‣ The experiences of fathers are receiving increasing attention in literature and media

Paternal Perinatal Depression

‣ The prevalence of depressive disorders and risk factors during the postpartum period has grown over the past few decades with increasing awareness and concern about the impact and experience of fathers

‣ While maternal postpartum depression is well documented and its impact on child wellbeing extensively examined, emerging literature suggests that the incidence of fathers who experience paternal perinatal and postpartum depression (PPD) is currently under-researched and under-screened leaving many fathers undiagnosed and suffering in silence

‣ Emerging research suggests that paternal perinatal depression (PPD) is commonly experienced by new fathers with prevalence estimate rates ranging anywhere from 4 to 25 percent for new dads

‣ Men are less likely to report depressed feelings during pregnancy and the postpartum period, making it difficult to account for accurate rates and prevalence (McKoy, 2012)

Paternal Perinatal Depression

‣ Typically seen as an issue in the area of maternal-child health, the importance of a woman’s emotional well-being during the transition to parenthood is well documented and recognized, with routine screening during the perinatal period which encompasses pregnancy through one year postpartum

‣ The birth of a child and transition to parenthood is one of the most profound events in a man’s life and involves dealing with major changes in daily living along with transforming his identity, his romantic relationship and his standing in the community

‣ In a bygone era, a father’s lack of engagement and relegation to the role of ancillary helper were acceptable, but today's expectations of fathers is that they will provide, nurture and care for their offspring from the start

What is Paternal Perinatal Depression (PPD)?

‣ Paternal perinatal depression is a non-psychotic depressive disorder that occurs before or after the birth of a child during the perinatal period

‣ The perinatal period is defined as the onset of pregnancy to 12 months postpartum

‣ Researchers now acknowledge that PPD is also the product of psychosocial causes. It can, therefore, be presumed that such factors would also have an impact on the mental health of involved fathers in the postnatal period

‣ According the DSM-5 PPD is a major depressive episode “with peripartum onset if onset of mood symptoms occurs during pregnancy or within 4 weeks following delivery”

Manifestations of PPD In Men

Similar to mothers which include: ‣ Decreased appetite‣ Sleep disturbances‣ Feeling overwhelmed‣ Somatic symptoms‣ Sadness‣ Concentration‣ Irritability‣ Bonding difficulties with baby(APA, 2013)

Manifestations and Symptoms

‣ Feeling sad, hopeless, empty, or overwhelmed

‣ Crying more often than usual ‣ Worrying or feeling overly

anxious‣ Feeling moody, irritable, or

restless‣ Oversleeping or being

unable to sleep when your baby is asleep

‣ Having trouble concentrating and making decisions

‣ Frequent feelings of anger or rage

‣ Losing interest in activities that are usually enjoyable

‣ Suffering from physical aches and pains

‣ Eating too little or too much‣ Avoiding friends and family‣ Having trouble bonding with

baby‣ Persistently doubting ability

to care for baby‣ Thinking about harming self

or baby

Manifestations of PPD In Men

Men have different and distinct symptoms which include: ‣ Increased levels of stress‣ Financial Stress‣ Anger attacks‣ Affective rigidity (failure to express emotions)‣ Self criticism‣ Risky behavior: Alcohol and drug abuse,

unsafe driving ‣ Unhealthy sexual relationships or infidelity‣ Escapist behavior, such as spending

excessive time watching television or at work‣ Isolation, and withdrawal from relationships,‣ Changes in work or employment activity

(working more or less)‣ Poor physical health(Epifanio et al., 2015; Speisman et al., 2011; Condon et al., 2004).

Depression Screenings for PPD in Men

‣ No specific tests for Male PPD sometimes regular screens for detecting MD are used to assess post birth. These tools: include:

‣ Beck Depression Inventory (BDI)

‣ Center of Epidemiologic Studies Depression Scale (CES-D), and the Patient Health Questionnaire

‣ (PHQ-9

‣ The Edinburgh Postnatal Depression Scale (EPDS)

The Edinburgh Postnatal Depression Scale (EPDS)

‣ The Edinburgh Postnatal Depression Scale was first developed (1987) by Scottish health centers in Edinburgh and Livingston

‣ The EPDS is now well-established for use in both the prenatal and postpartum periods in women and has been translated into several languages

‣ EPDS was developed as a screen specifically for PPD in women. It is a self-administered, ten question quiz in which participants rate how they have been feeling for the past weeks electing from four possible answers for each question

‣ The highest possible score on the test is 30, indicating the most depressive symptoms present. The lowest possible score is 0, indicating the least depressive symptoms

‣ The only scale validated for use among men (Matthey et al. 2000)

Edinburgh Postnatal Depression Scale (EPDS)

Scores‣ 0-9 Scores in this range this may indicate the presence of some symptoms of distress that may be short-lived and are not likely to interfere with day to day ability to function at home or at work. However if these symptoms have persisted more than a week or two further enquiry is warranted as to the cause

‣ 10-12 Scores within this range indicate presence of symptoms of distress that may be discomforting. We suggest that you repeat the EDS in 1- 2 weeks time for women scoring in this range and if the scores increase to above 12 assess further and consider referral to a mental health specialist or general practitioner for review.

‣ 13 + Scores above 12 require further evaluation and possible referral to a perinatal mental health specialist. Repeat the EDS at intervals top monitor progress.

Risk Factors for Paternal Perinatal Depression

‣ Although the research is still in its nascent stages, the available literature lists several risk factors that have been identified as contributing to paternal perinatal depression:

‣ Relational Factors• Partner with maternal depression

(Philpott, 2016)• Lack of social support (Gao et al.,

2009; Wilson, 2008) • Unplanned pregnancy (Oladosu,

2012)• Father absence• Problems in the partner relationship

Risk Factors Continued ‣ History of Psychiatric Disorders: Depression and

Anxiety most common (Nishimura & Ohashi, 2010)

‣ Educational Level (Musser et al., 2013)

‣ Paternal Age: Young fathers at greater risk (Philpott, 2016)

‣ Employment: Unemployment, underemployment (Glasser & Lerner-Geva, 2019)

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Impacts of Paternal Postpartum Depression on

Children ‣ Paternal depression can negatively affect infant care and bonding, is stressful to

the family unit, overall, has been linked to later child psychopathology, offspring of depressed parents are at higher risk for depression (Weissman et al., 2006)

‣ Conduct and emotional disorders, hyperactivity, as well as delays in language (Grace et al., 2003) (Buist, Morse & Durkin, 2002).

‣ Behavioral problems (e.g., temper tantrums, sleep patterns, neurotic and antisocial behavior, etc.) (Goodman et al., 2011) ‣ Delays in cognitive development (Grace et al., 2003).

‣ Untreated PPD is also associated with an increased incidence of psychiatric disorders in children (Ramchandani et al., 2011)

‣ Studies that control for gender show that paternal depression may be more associated with externalizing problems, such as behavioral issues and substance abuse, whereas maternal depression appears to have a closer link to mood and anxiety problems in offspring (Ramchandani et al., 2011).

Impacts of PPD on Partner & Family Overall

‣ Untreated PPD has been shown to negatively impact the entire family system including children's social and emotional development, behavior, and attachment (Fletcher et al., 2011; Giallo et al., 2013; Rominov et al., 2016)

‣ Partner: Fewer positive behaviors such as warmth, sensitivity and responsiveness, and increased negative behaviors such as disengagement and hostility (Rominov et al., 2016)

Quentin’s Story ‣ Came to the Father’s First program after finding out

he was going to be a dad for the first time

‣ 25 years of age

‣ College graduate

‣ Expecting a daughter with partner of 3 years

‣ Unmarried

‣ Living separately

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Treatment for Paternal perinatal depression

‣ Approximately 10% of fathers will experience a depressive episode during the perinatal period (Paulson and Bazemore, 2010)

‣ This figure represents twice the rate found in the general male population (Anokye et al., 2018)

‣ No specific treatment studies or guidelines that provide direction or best practices for PPD

‣ This is in contrast to maternal perinatal depression (MPD), where there are several treatment guidelines including manualized psychotherapies, such as interpersonal therapy (IPT), cognitive behavioral therapy (CBT), and pharmacological recommendations (Grigoriadis and Ravitz, 2007; Misri et al., 2004)

Treatment for PPD‣ The overall standard of care for treating PPD

generally continues to be antidepressants, psychotherapy or both

‣ Men are more likely to agree to psychotherapy if that option is presented as a way to protect or restore some aspect of their masculinity, as in the ability to provide for the family or contribute to the family’s well-being

‣ Getting men to seek help when they are depressed can be a challenge

Interventions Interventions delivered in the antenatal/ pregnancy period include:‣ Parenting education class focusing on the

physiological, psychological, and general process of childbirth‣ Understanding the role of the father / what to expect as a new father ‣ Clarifying partner support expectations

‣ Preparing for labor and birth‣ Caring and nurturing baby ‣ Understanding breast-feeding‣ Childcare and household tasks‣ Additional resources ( educational, financial,

employment, etc.)‣ Child support, family court help

Recommendations for Clinicians

Promising practices for combatting PPD:‣ Pamphlets for men about paternal perinatal depression and

the normal stresses and changes that accompany caring for a new baby; can be sent home with new mothers, when parents visit an obstetrics clinic for prenatal or a postpartum exam or pediatric visit

‣ Prenatal classes can be offered that are specifically designed exclusively for men that are taught by male-centric instructors

‣ A telephone help line may be designated for counseling fathers with questions or depressive symptoms

‣ Additional services in working with fathers include: • weekly support groups, father child activities, family centered

activities

Fathers First Focus Areas‣ Areas of Focus and Priorities

‣ Parenting Services

‣ Mental Health

‣ Child Support & Paternity

‣ Healthy Relationships

‣ Community-Based Collaborations

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Fathers First Program ‣ The Fathers First program is place where fathers

can come together and talk. Fathers First is an organizational movement that seeks to inspire, mobilize and equip fathers to become good influences in the lives of their children across the lifespan

Offers four programs for fathers ‣ Daddy Boot Camp‣ Dr. Dad‣ 7 Habits ‣ 24/7 Dad

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Conclusions ‣ Paternal PPD is a relatively new field of study, but it

is established that the rate of depression in men during the postpartum period exceeds that for men in the population at large

‣ This disorder affects not only the men themselves, but also their children and romantic partner

‣ Although no perfect screening tool exists for detecting paternal PPD, the same EPDS that is used for women appears to be a valid instrument for screening men

Conclusions‣ Main challenge at present is getting men to seek help

when they feel anxious, overwhelmed, angry, or sad‣ Educational and treatment programs that specifically

target men experiencing PPD may make a significant contribution to the overall mental health for men and the entire family

‣ Future research must focus on better education and public awareness about paternal perinatal depression, better screening tools specifically for men, and best practices in treatment alternatives to psychotherapy or medications

Conclusions‣ Working within the field of parent-child health has led to an

understanding of the importance of incorporating holistic interactive, gender-based approaches to identification, assessment and treatment of paternal postpartum depression

‣ Connecting how parents think and behave during pregnancy and the early years of their child’s life influences future child development, thus providing fathers with an opportunity to think through, understand and challenge their own caregiving relationship assists in the constructing of a healthy social-emotional environment for parent, baby and the overall family system

‣ Mental health professionals and other disciplines in primary care are well-positioned for screening and facilitation of conversations for both families and providers in order to openly wrestle with this dilemma of what it means to facilitate meaningful male-centered mental health interventions

Q & A ‣ Thank you!

Thank you!

Please feel welcome to contact Dr. Lena Green at: LLG212@nyu.edu

If you have questions about CTAC, please contact ctac.info@nyu.edu

Resources‣ The Akira Center- Free community based social service

organization offering group-based services @ http://akiracenter.com/

‣ Daddy Bootcamp is a 3-hour workshop for new and expectant dads ‣ Doctor Dad Program: Workshops are great for new and expectant dads as it

helps increase fathers' health literacy by providing men with the knowledge and skills they need to successfully care children right from the start‣ 7 Habits of A 24/7 Dad: Eight-hour workshop that combines the fundamental fathering principles from National Fatherhood Initiative's 24/7 Dad programs with Franklin Covey’s timeless 7 Habits program

‣ 24/7 Dad Program: The most comprehensive fatherhood program available with innovative tools, strategies, and exercises for fathers of all races, religions, cultures, and backgrounds! Developed by fathering and parenting experts, it focuses on the characteristics men need to be good fathers 24 hours a day, 7 days a week

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Resources Continued‣ National Fatherhood Initiative resources can be found

at https://www.fatherhood.org/

‣ National Responsible Fatherhood Clearinghouse resources can be found at https://www.fatherhood.gov/

‣ Edinburgh Postnatal Depression Scale (EDPS)https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/practicing-safety/Documents/Postnatal%20Depression%20Scale.pdf

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