Original article

Keywords

Depression

Postpartum

Fathers

Prevalence

Men

Gender

Svend Aage Madsen,PhDDepartment of Psychology,Play Therapy & SocialCounselling, CopenhagenUniversity Hospital, Rig-shospitalet, Denmark

Tina Juhl, MSDepartment of Psychology,Play Therapy & SocialCounselling, CopenhagenUniversity Hospital, Rig-shospitalet, Denmark

E-mail: svaam@rh.dk

Online 27 February 2007

26 Vol. 4, No. 1, p

p.

Paternal depression in thepostnatal period assessedwith traditional and maledepression scales

Svend Aage Madsen and Tina Juhl

Abstract

Background: The occurrence of postnatal depression in fathers has begun to receive attention in the

international research literature. The Edinburgh Postnatal Depression Scale (EPDS) assessment tool has

been validated for men. However, identification of such men has been hindered by the use of assessment

tools that may not be sensitive to the particular depressive symptoms experienced by men. So far the

problem of male depressive symptoms has not been included in research on men’s postnatal depressions.

Methods: As part of a fatherhood research programme, the EPDS and the Gotland Male Depression

Scale (GMDS) were administered to 607 fathers 6 weeks after the birth of their child.

Results: 549 (90.4%) fathers were assessed for the presence of depressive symptoms. The prevalence

was 5.0% with EPDS (cut-off �10) and 3.4% with GMDS (cut-off �13). While 2.1% of the fathers had

scores above the cut-off on both scales, 3.1% were assessed using only the EPDS and 1.3% with only the

GMDS.

Conclusion: Our findings indicate that better methods for identifying men with postnatal depression

need to be developed and should consist of assessment scales that also include male depressive

symptoms. � 2007 WPMH GmbH. Published by Elsevier Ireland Ltd.

Introduction

The transition to parenthood has a great psy-

chological impact on both mothers and fathers

[1,2]. This has been acknowledged in relation

to women for many years and many studies

have focused on postnatal depression in

women [3]. Postnatal depression, as measured

by the Edinburgh Postnatal Depression Scale

(EPDS), affects approximately 10–14% of post-

partum women [4]. Some studies have shown

that postnatal depression can already occur

during pregnancy, in this case it is referred

to as antenatal depression, and that it can also

occur among fathers-to-be [5–7]. A growing

number of studies on postnatal depression

in women have also taken note of the father’s

psychological wellbeing [8,9]. Only a few stu-

dies have had their main focus on paternal

26–31, March 2007

depression [6,10]. The existing studies – most of

them comprising a small sample size – report

2–24% of fathers with postpartum depression

[9]. These very divergent findings reflect differ-

ent methods and cut-off points, but they also

indicate that this is a very new research area. It

was only in 2000 that Matthey et al. [5] vali-

dated the EPDS for use in fathers postpartum.

Studies have found a correlation between

maternal postpartum depression and paternal

postpartum depression [9]. The importance of

raising the awareness of men’s postnatal depres-

sion has been emphasised by research indicat-

ing that paternal depression has a specific and

detrimental effect on their children’s early

behavioural and emotional development [11].

In the general population, twice as many

women as men are diagnosed with depression

[12]. Traditionally, it has often been hypothe-

� 2007 WPMH GmbH. Published by Elsevier Ireland Ltd.

Original article

sised that this is due to women’s physiology for

reproductive functioning [13]. Since the end of

the 1990s, more studies have focused on

whether men show other symptoms of depres-

sion and the concept of male depression has

been discussed [3,14]. Studies have shown that

anger attacks, affective rigidity, self-criticism,

alcohol and drug abuse are symptoms that more

often occur in men suffering from depression

[15–17]. In Europe, some authors refer to these

symptoms as the Male Depressive Syndrome [18].

Walinder & Rutz [14] proposed this syndrome

following the experiences of the Gotland Study,

which showed that education of general practi-

tioners about depressive illness resulted in a

statistically significant reduction in thenumber

of female suicides, leaving the rate of male

suicides almost unaffected. These experiences

led to the development of the ‘Gotland Male

Depression Scale’. In a modified version, this

scale has been used in other studies of the Male

Depressive Syndrome [18]. American authors in

the field have used the term Masked Depression to

designate the male symptoms [19]. Examining

depression related to fatherhood in first-time

fathers, Condon et al concluded in 2004 that it

is important to find another method to detect

postnatal depression in fathers because they

often show other symptoms [10]. Furthermore,

clinical work with fathers suffering from mood

disorders related to parenthood indicates the

importance of identifying symptoms other

than those used in traditional instruments

for assessing depression, e.g. the Beck Depres-

sion Inventory and the EPDS. Therefore, the

purpose of this study was not only to indicate

the prevalence of postnatal depression in

fathers in a Danish population but also to

investigate whether male depressive symptoms

should be included when screening for and

diagnosing men with postnatal depression.

We hypothesised that integrating the GMDS

into the questionnaire would make it possible

to detect some fathers with possible depression

who would not score above cut-off on the EPDS.

Methods

Participants

In this study, 607 men whose partner

consulted the maternity ward at Copenhagen

University Hospital, Rigshospitalet, were

recruited. All men came from the same city

area so the generalisation may be somewhat

limited. However, Denmark is a small country

with a very homogenous population of only

51/2 million inhabitants. Women living in the

hospital’s catchment area will deliver at the

Copenhagen University Hospital. Some others

also give birth there by making use of the

Danish right to freely choose a hospital or

because of the specialisations available at the

Copenhagen University Hospital. Only an insig-

nificant number of the participating fathers

were partners of mothers belonging to a special

patient group. All socio-economic classes are

represented in the sample but data on the

fathers’ employment show that the interviewed

fathers had a somewhat higher education than

the average population in Denmark.

The fathers were contacted consecutively

during December 2004 through April 2005 by

midwives at prenatal courses and at prenatal

consultations. These two arenas for recruitment

were chosen to ensure participation from

fathers who had not attended the prenatal

courses, which nearly all first-time fathers do

in Denmark [2]. When the man did not partici-

pate, the woman was asked to take the recruit-

ment papers home for him. The 607

participants were recruited as follows: at the

courses, 550 men were asked to participate and

493 (89.6%) answered positively. A further 135

were contacted via consultation and 114 (84.4%)

responded positively. Six weeks after the birth

of their child, the 607 fathers were offered a

questionnaire containing the Edinburgh Post-

natal Depression Scale (EPDS) [20] and the Got-

land Male Depression Scale (GMDS) [21]. In total,

549 fathers returned completed questionnaires

for an overall response rate of 90.4%. Mean age

of the men was 32 years (range 22–57 years). A

total of 468 (85.2%) were first time fathers, while

81 (14.8%) had had children before. Of the 549

(99.5%) fathers who returned filled out ques-

tionnaires, 546 were living with the mother.

The Danish National Committee on Biome-

dical Research Ethics received an application

with the research protocol of the study. The

committee declared that they had no objec-

tions to our carrying out the project.

Measures

The EPDS is a questionnaire with 10 self-report

items with a focus on the emotional and

Vol. 4, No. 1, pp. 26–31, March 2007 27

Original article

28 Vol. 4, No. 1, p

cognitive characteristics of depression, while

somatic symptoms are given less importance.

The EPDS has been validated for use postna-

tally and during pregnancy [22]. The EPDS is a

screening instrument in which a score of �13

is widely used to indicate a probable depressive

disorder in women. Validation of the scale

shows that all women found to have definite

major depression when interviewed have

scored above 12 on the scale. Use of this thresh-

old gave an overall sensitivity of 86% and a

specificity of 78% for all forms of depression

[20]. According to Matthey et al’s validation

study [5] on 208 fathers, the EPDS is both

reliable and valid for fathers. Using caseness

of depression it discriminates between dis-

tressed and non-distressed fathers. The opti-

mum cut-off score for this is �10 on the

EPDS, which indicates probable depression

in men. Using this score, 71.4% of depressed

men and 93.8% of non-depressed men are cor-

rectly classified and only 7% are misclassified.

The Gotland Male Depression Scale is also a

screening instrument and consists of 13 self-

report items. It was developed to improve the

recognition of major depression in males by

focussing on ‘male depressive symptoms’ [23].

A score of �13 indicates a possible depression.

The GMDS has been validated by Zierau et al.

[21], who compared it with the Major Depres-

sion Inventory in a population of male patients

treated for alcohol dependency. The preva-

lence of depression, as well as the prescription

of antidepressants, were used as indices of

validation. The GMDS was shown to have an

adequate internal validity made up of internal

consistency (Cronbach coefficient alpha = 0.86)

and internal homogeneity (Loevingers coeffi-

cient = 0.37). The prevalence of depression

according to the Major Depression Inventory

was 17%, while according to the Gotland Male

Depression Scale 39% of the patients had a

probable or definite depression and should

be considered for treatment with antidepres-

sants. The GMDS should be seen as a first

attempt to assess male depressive symptoms.

Table 1 Fathers at risk of postnatal depression

EPDS 27 (5.0%)*

GMDS 18 (3.4%)y

Postnatal Depression including

EPDS + GMDS

34 (6.5%)z

Completed questionnaires: *542, y529, z524.

Procedures

Risk of postnatal depression in fathers was

defined as a total score of �10 on the EPDS

and �13 on the GMDS. Internal validity, mea-

sured from the mean scores on the two scales,

was analysed using the Mann–Whitney non-

p. 26–31, March 2007

parametric U test. Identities and differences

between answers on the tests were analysed

using Fisher’s exact test (2-sided) and Cohen’s

kappa measurement of agreement.

Results

Of the 607 men, 549 (90.4%) returned the

questionnaire. The EPDS was correctly com-

pleted by 542 of the 607 fathers (89.3%) and

the GMDS by 529 (87.1%), while 524 (86.3%) of

the 607 participating fathers had completed

both the EPDS and the GMDS. As measured by

the EPDS, 5.0% of fathers who had cut-off

scores of �10 were at risk of postnatal depres-

sion. As measured by the GMDS, 3.4% of fathers

who had a cut-off score of �13 were at risk of

depression. The percentage of fathers who

scored above the cut-offs on both scales was

2.1%, while 3.1% were assessed using only the

EPDS and 1.3% using only the GMDS. In all,

6.5% of the participants had a score above the

cut-off on either one of the scales or on both

and were thus at risk for postnatal depression

according to the principles laid down here (see

Table 1).

Comparisons of the two scales show that

67.6% in the at-risk group scoring above the

cut-off values are detected by only one of

the scales. The number of men scoring above

the cut-off on the EPDS but below the cut-off on

the GMDS was 47.1% of the 34 fathers at risk

for postnatal depression. Seven men scored

above the GMDS cut-off but below the EPDS

cut-off, i.e. 20.6% of the at-risk fathers (see also

Table 4). Of the 27 men scoring above the cut-

off on the EPDS, 40.7%, also scored above the

GMDS cut-off, while 61.1% of the 18 men scor-

ing above the cut-off on the GMDS also scored

above the cut-off on the EPDS (see Fig. 1).

The results of the analysis for internal valid-

ity using the Mann–Whitney U test are

presented in Table 2. Results show that the

median from those fathers scoring above

the cut-off is significantly different from the

Original article

Figure 1 Scatterplot of the Edinburgh Postnatal Depres-

sion Scale (EPDS) and the Gotland Male

Depression Scale (GMDS) scores.

median of those fathers scoring below the cut-

off and applies to all items of both scales.

An analysis of the relationship between

the two median scores for the two scales is

Table 2 Analysis of median values for each item

EPDS

Not being able to laugh and see the funny side of thing

Not looking forward with enjoyment to things

Blaming oneself unnecessarily when things went wrong

Being anxious or worried for no good reason

Having felt scared or panicky for not very good reason

Feeling things have been getting on top of one

Having been so unhappy that it became difficult to slee

Having felt sad or miserable

Being so unhappy that it led to crying

Thoughts of harming oneself have occurred

GMDS

Lower stress threshold

Aggressiveness, low impulse control

Feeling of being burnt out and empty

Constant, inexplicable tiredness

Irritability, restlessness, dissatisfaction

Difficulty making ordinary everyday decisions

Sleep problems

In the morning especially, feeling of disquiet/anxiety/disp

Abusive behaviour, hyperactive behaviour, under- or ove

Antisocial behaviour

Depressive thought content

Complaintiveness

Hereditary loading; depressive illness, alcoholism, suicide* Mann–Whitney U test.

presented in Table 3 and shows that scores on

the single items of the GMDS are significantly

related to the total score of the EPDS. Further-

more, results show that a high score on any

single item of the GMDS is related to a high

score on the total GMDS scale.

A comparison of the two scales using Fish-

er’s exact test (2-sided) is shown in Table 4. The

results (P < 0.0001) indicate that the responses

in the two scales are related.

The t-test with Cohen’s kappa measurement

of agreement shows Kappa = 0.49, which indi-

cates a fair to moderate but no substantial

relationship.

Discussion

Just as research on women’s postnatal depres-

sion took a long time to establish itself, so

research into men’s depression related to

fatherhood still has a long way to go before

Median (min-max) P*

EPDS < 10 EPDS � 10

s 0 (0–2) 1 (0–3) <0.001

0 (0–2) 1 (0–2) <0.001

1 (0–3) 2 (0–3) <0.001

1 (0–3) 2 (0–3) <0.001

0 (0–3) 1 (0–3) <0.001

0 (0–3) 2 (1–3) <0.001

p 0 (0–2) 1 (0–3) <0.001

0 (0–2) 1 (1–3) <0.001

0 (0–2) 0 (0–2) <0.001

0 (0–2) 0 (0–2) <0.001

Median (min-max) P*

Gotland < 13 Gotland � 13

1 (0–3) 2 (1–3) <0.001

0 (0–2) 2 (0–2) <0.001

0 (0–3) 2 (1–3) <0.001

0 (0–3) 2 (1–3) <0.001

0 (0–2) 2 (1–3) <0.001

0 (0–2) 1 (0–3) <0.001

0 (0–3) 3 (0–3) <0.001

leasure 0 (0–2) 1 (0–2) <0.001

reating 0 (0–2) 0 (0–3) <0.001

0 (0–1) 1 (0–2) <0.001

0 (0–1) 1 (0–3) <0.001

0 (0–2) 1 (0–3) <0.001

0 (0–3) 0 (0–3) 0.009

Vol. 4, No. 1, pp. 26–31, March 2007 29

Original article

Table 3 An analysis of the relationship between the median scores for the EPDS and GMDS scales

Median EPDS score (25–75 percentile)

Item no. n Low score on

GMDS item (�1)

n High score on

GMDS item (>1)

P*

G_1 > 1 475 3.0 (1.0–5.0) 67 6.0 (4.0–10.0) <0.001

G_2 > 1 467 3.0 (1.0–4.0) 22 10.0 (6.0–12.5) <0.001

G_3 > 1 459 3.0 (1.0–4.0) 36 9.0 (6.0–10.0) <0.001

G_4 > 1 457 3.0 (1.0–4.0) 32 7.5 (5.0–9.8) <0.001

G_5 > 1 456 3.0 (1.0–4.0) 44 7.5 (5.0–10.0) <0.001

G_6 > 1 464 3.0 (1.0–4.8) 15 9.0 (5.0–11.0) <0.001

G_7 > 1 429 2.0 (1.0–4.0) 65 5.0 (3.0–9.0) <0.001

G_8 > 1 470 3.0 (1.0–5.0) 7 8.0 (6.0–18.0) <0.001

G_9 > 1 470 3.0 (1.0–5.0) 12 9.0 (3.8–11.5) <0.001

G_10 > 1 475 3.0 (1.0–5.0) 1 20 0.081

G_11 > 1 475 3.0 (1.0–5.0) 4 14.0 (9.3–19.5) 0.001

G_12 > 1 474 3.0 (1.0–5.0) 9 9.0 (6.0–11.0) <0.001

G_13 > 1 449 3.0 (1.0–5.0) 32 4.0 (2.0–6.8) 0.014* Mann–Whitney non-parametric test.

30 Vol. 4, No. 1, p

there is consensus on definitions and before

usable scales have been developed and vali-

dated.

The high response rates from the men in

this study show that men as fathers are very

interested in, and willing to contribute to,

research into the psychological aspects of

men’s transition to fatherhood.

The instruments used in this survey are both

self-report instruments and are thus not provid-

ing a clinical diagnosis of depression. Therefore

the results have to be seen as indicating prob-

able depression, meaning that some fathers

scoring below the cut-off values may suffer

from depression and some scoring above may

not. However, the validation studies for both

instruments [5,14] have shown that the cut-off

values used give the best estimate of prevalence

of depression at 6 weeks postpartum.

Besides being the first study on Danish

men’s psychological problems relating to the

birth of their children, this study incorporates

‘male depression’ symptoms by using the

GMDS. The inclusion of these symptoms has

Table 4 Fisher’s exact test (2-sided)

Gotland score 13+ Total

0.00 1.00

EPDS

score 10+

.00 490 7 497

1.00 16 11 27

Total 506 18 524

p. 26–31, March 2007

not been done before in non-clinical samples

or in assessing postnatal depressions. The find-

ing that 6.5% or 4000–4500 Danish men a year

are at risk for postnatal depression is, itself,

important, since very little attention has been

paid to this problem in health services or

among health professionals. The 5% preva-

lence rate for men’s postnatal depression using

the EPDS and its traditionally accepted symp-

toms of depression is very much in accord with

Matthey et al’s validation study [5].

When including the GMDS with male

depression symptoms, the rate of prevalence

(6.5%) is still within the range of former stu-

dies using only the EPDS. As shown by Winkler

et al. [23], symptoms like the ones represented

in GMDS are more frequent in male than in

female inpatients diagnosed with depression.

Our study shows that among the 5% of parti-

cipants scoring above the cut-off on the EPDS,

40.7% of the men also scored above the cut-off

on the GMDS. This indicates that among men

with postnatal depression detected using the

traditional symptoms included in the EPDS, it

is important to consider the male-specific

symptoms.

It should be noted, however, that since 20.6%

of the at-risk fathers in the present study have a

score above the cut-off value only on the GMDS

and a score under the cut-off value on the EPDS,

a considerable number are detected only with

this male symptoms scale. Presupposing that

the GMDS is actually able to detect individuals

Original article

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