Matan White, MD

	Maternal postpartum depression (PPD) is a widely studied and discussed phenomenon, whereas much less is known about the concept of paternal PPD. Nonetheless, recent studies have indicated that depression in new fathers is a significant public health concern.

 calculated the overall rate of paternal depression in the prenatal and postpartum period to be 10.4%, with the U.S. rate higher at 14%. Considering that the estimated rate of depression in the general population for men in this age group is lower at 4.8% 

 this period poses a substantially increased risk for developing depression in men, just as it does in women. Even though men are at risk for up to a year after their child is born, data suggest that the rate of depression peaks between the 3- and 6-month postpartum period.

	Why the marked increase in depression? The causes are likely multifactorial, including personal or family predisposition to depression, shifting family dynamics, adjustment to parenthood, lack of sleep, and even hormonal changes. While it may be self-evident that hormonal changes occur in pregnant, peripartum, and lactating women, changes also happen (but are far less studied) in men. For example, studies have found that men experience a significant decrease in testosterone levels while their wives are pregnant 

 and this effect could extend to the postnatal period 

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	Changes in the levels of other hormones, including estrogen, vasopressin, and prolactin, have also been noted. While these changes likely reflect adaptive shifts to fatherhood by facilitating the father’s focus toward caregiving and nurturing, these fluctuations also likely increase men’s susceptibility to depression during this period.

	Postpartum depression in men could have a more insidious onset than it does in women. Even though men experience traditional symptoms of depression like sad mood, decreased interest level, decreased energy and concentration, sleep problems, guilt, and even suicidal thoughts, they may be reluctant to endorse these in conversations with their health care team or in self-report questionnaires. Rather, men may present with less obvious symptoms like avoidance, withdrawal from social activities, cynicism, anger outbursts, irritability, and self-criticism 

 They may also mask their emotional pain by overworking, over-exercising, or changing their sexual behavior 

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	In fact, a study suggests that men are more likely to endorse anger attacks and aggressiveness, lower stress threshold, burnout, affective rigidity, self-criticism, and alcohol and drug abuse 

 Relying only on the disclosure of traditional symptoms of depression could lead to a missed diagnosis of depression.

	Why is it important to diagnose and treat men with postpartum depression? There are significant consequences to paternal depression in the postpartum period. It not only negatively impacts the father’s sense of well-being, but it also interferes with his care of and bonding with his child. In addition, it puts significant stress on the family unit. Unsurprisingly, paternal PPD has also been associated with increased risk of emotional and behavioral problems in children and later psychopathology.

	A large family study of U.S. children and their families found that paternal PPD was linked to decreased paternal engagement in positive enrichment activities such as reading 

 Ramchandi and colleagues found that fathers who were depressed both prenatally and during the postpartum period were more likely to have children with emotional and conduct disorders, hyperactivity, and social problems at both 3.5 and 7 years of age 

 Interestingly, this effect was more pronounced in boys.

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	How can we engage men in seeking help and getting support for their needs as fathers? Multiple points of contact with an expecting or new father may allow for implementation of screening, prevention, education, and referral/treatment measures. For example, if a father-to-be is encountered in a primary care setting or a specialty clinic, he could be assessed for risk factors (table 1), screened using a depression questionnaire (table 2), and engaged in a conversation about potential symptomatology of depression (table 3).

	Since one of the most striking predictors of depression in new fathers is maternal PPD in their partners, new fathers whose wives screen positive for PPD should also be screened for depression. Fathers could also be screened in clinics where they bring their newborn for checkup or treatment.

Next: "The prenatal period may present an excellent opportunity to educate a father-to-be about the challenges of his shifting role from being a partner to being a parent"

	Once risk factors for depression are identified, interventions can focus on the stage-specific needs of men (prenatal or postnatal) and the suspected causes of depression 

 For example, the prenatal period may present an excellent opportunity to educate a father-to-be about the challenges of his shifting role from being a partner to being a parent. He may be referred to father-centered education programs where he could become more informed about birth and postpartum routines, infant medical conditions, and infant development.

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	He may also be given resources to facilitate awareness of paternal postpartum depression and to address the stigma that may be associated with it. The websites of Postpartum Support International and PostpartumMen include lists of helpful resources 

www.postpartum.net/get-help/resources-for-fathers

	In the postnatal period, the father may struggle balancing personal and work needs with the demands of being a parent. He may feel frustrated about his changing lifestyle and sexual relationship with his partner but also about not being able to be more involved in the care of his infant. During this period, referrals to enhance a positive relationship with his partner and positive parenting skills maybe very helpful. If significant depression is suspected, referral to a mental health professional for further evaluation and treatment with medication (eg, an SSRI) or psychotherapy should be considered.

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Articles

Maternal postpartum depression (PPD) is a widely studied and discussed phenomenon, whereas much less is known about the concept of paternal PPD. Nonetheless, recent studies have indicated that depression in new fathers is a significant public health concern.

Author | Matan White, MD

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