171122 Assessing and Managing Paternal Mental Health Issues
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Copyright EMAP Publishing 2017 This article is not for distribution Nursing Practice Keywords Antenatal clinics/Childbirth/ Depression/Fathers/Relationships Discussion This article has been Mental Health double-blind peer reviewed In this article... ● Why it is important to raise awareness of paternal mental health issues ● Symptoms of postnatal depression in men ● Assessment tools for use in new fathers Assessing and managing paternal mental health issues Key points Authors Jane Hanley is honorary lecturer in perinatal mental health at Swansea The mental health of University and course director at PMH Training; Mark Williams is an international fathers is not as well campaigner and trainer in perinatal and paternal mental health. researched as that of mothers Abstract How do men cope with pregnancy, childbirth and fatherhood? How do these events affect their mental wellbeing, their relationships with their partners and It is increasingly their attitudes towards their newborn child? Paternal mental health has long been recognised that neglected, but we now know that it is crucial to monitor it and recognise, assess and fathers can have treat any mental health issues experienced by men in the perinatal period. This article postnatal depression offers an overview of this under-researched topic and provides guidance for health or post-traumatic professionals in contact with future and young fathers. stress disorder Citation Hanley J, Williams M (2017) Assessing and managing paternal mental health Paternal depression issues. Nursing Times [online]; 114: 12, 26-29. is under-diagnosed because it does not necessarily manifest hile maternal mental A few studies have explored the atti- through classic health is well researched, tudes of potential fathers and found that symptoms the mental health of men most men had used contraception and had Wbefore, during and after the not contemplated the thought of their Allowing men birth of their child is not (Ramirez and partner becoming pregnant (Kågesten et to explore their Badger, 2014). Investigations into the causes al, 2015). Approaching fatherhood trig- childhood and consequences of paternal mental health gered a range of emotions – some experiences, issues is a relatively new field so data on this expressed anxiety, others anger and guilt. anxieties and mental subject is limited. Two further reasons for Some men felt it occurred at a difficult health issues can the paucity of data is that high attrition rates period because of competing demands on be cathartic compromise any statistical research find- their time and resources. Their reactions ings (Woodall et al 2010; Sherr et al, 2006) were often dictated by their past experi- Fathers should be and that men tend to self-manage their con- ences of dealing with difficult situations. included in antenatal ditions rather than consult professionals Feelings of lack of control and freedom and postnatal care (Wendt and Shafer, 2016). This article raises have been known to alter relationship the awareness of paternal mental health dynamics and increase the risk of paternal issues, and provides guidance on how to anxiety and depression. What was evident recognise, assess and manage them. in the studies was that most men were pre- pared to accept their parental responsibili- Antenatal period ties (Lindberg et al, 2017; Wilkes et al, 2012). For many couples a pregnancy is welcome With limited evidence on a man’s psy- but for some, it may be a shock or a disap- chological preparation for fatherhood, pointment. An unplanned pregnancy can suppositions are often made about his have a negative effect on both partners, but suitability for the role, and it is often while there are numerous studies on the assumed that he has sound psychological impact on women, the effect on men is not health. However, he may have a mental so well documented (Wellings et al, 2013). health disorder – for example autism or Nursing Times [online] December 2017 / Vol 113 Issue 12 26 www.nursingtimes.net Copyright EMAP Publishing 2017 This article is not for distribution Nursing Practice Discussion Asperger’s syndrome – that so far has gone 2007). Studies in animals have shown a unrecognised by health professionals. We decrease in paternal testosterone levels suspect that many men have a history of and increased prolactin levels: this made anxiety, but this is difficult to quantify. males more likely to respond to their off- Equally difficult to quantify is the number springs’ need for attention (Alexander, of future fathers who experience psychotic 2014; Fleming et al, 2002). episodes, such as those seen in bipolar dis- Maternal depression has been shown to order, which they may successfully have the most significant correlation to manage without external help until the paternal depression (Davé et al, 2010; Wee ‘trauma’ of an impending birth. et al, 2011). The reasons for this are unclear. There is a paucity of information on One may be that the depressed mother is fathers’ insights into their own childhood unable to support her partner because of experiences and how these influence their her own illness. Another may be the mental health. We know that children of that around 10% of new fathers experience father’s inability to understand or cope depressed mothers are more at risk of it (Paulson and Bazemore, 2012). Ramchan- with his partner’s depression. Fathers may having depression themselves, and that dani et al (2011) found that men with a his- feel they are to blame because they are children of mothers who had high stress tory of severe depression, and a propensity unable to fulfil the societal expectation levels during pregnancy are more prone to for anxiety and depression during the that they should protect the family (Conde attention deficit hyperactivity disorder antenatal period, were more likely to have et al, 2011). and autism. It is entirely possible that a paternal depression in the postnatal The couple may have similar experi- future father’s own mother had perinatal period. ences of mental health difficulties trig- anxiety or depression. If such issues are Hormonal changes occur in men during gered by similar risk factors, and the disclosed and discussed, health profes- the perinatal period, with variations in the arrival of a child may exacerbate the prob- sionals can help the future father under- levels of oestrogen, cortisol, vasopressin lems already present in the relationship stand how his own parental relationships and prolactin that may increase the risk of (Demontigny et al, 2012). The father’s phi- may influence his relationships with his postnatal depression (Kim and Swain, losophy might be to avoid any upset and partner and child. stay in an unhappy situation to remain Box 1. with his child (Shorey et al, 2012). Post-traumatic stress disorder Case study: post- traumatic stress disorder Health professionals are increasingly Symptoms and signs aware that post-traumatic stress disorder A couple were elated when the woman Depressed fathers describe symptoms of (PTSD) can occur in men after the birth of a became pregnant. The husband’s job low mood and despondency, often occur- child, but there are few studies on its prevented him from engaging with ring shortly after the birth. They find it dif- impact on fathers and families. When a health professionals before the birth. ficult to concentrate on tasks and make traumatic delivery is witnessed, some When his son was delivered, he was decisions, feel lethargic and lack motiva- fathers’ response is one of powerlessness, unprepared for the surgical procedures tion. Summoning up the energy to engage helplessness or even intense fear. If unre- he witnessed during his wife’s with others is a challenge. They feel iso- solved, these issues can manifest as intru- caesarean section. lated and increasingly inadequate in their sive memories, flashbacks and night- During his wife’s second pregnancy, fathering skills, which often results in mares. The intensity of the distress may he ensured he attended the antenatal guilt. Life may seem “a long grey tunnel result in difficulties concentrating and classes. During one session, he confided from which there [is] no escape” (Wil- sleeping, which can lead to frustration and his anxieties to a health professional. liams, 2013; Chuick et al, 2009). If the father hyper vigilance around the infant (Stram- “The first time I felt that I was useless is severely depressed there is a risk of sui- rood et al, 2013; Bradley and Slade, 2011). and no one engaged with me during cide (Oliffe et al, 2012). There is an increased recognition that the labour. I don’t ever want to see The behaviours of depressed fathers PTSD is not confined to war situations. what I saw […] again and hated the tend to be different from those of Health professionals often assume they feeling of helplessness. […] I saw too depressed mothers. They may express have prepared men for an impending much. [Afterwards] I had nightmares their guilt through irritation or aggressive birth, but in a minority of cases, men’s when awake and racing thoughts when outbursts. To justify their own hostile fears have not been addressed and PTSD asleep. I had to have a drink at night behaviours, they may blame others for can ensue. There is increasing evidence to help me get to sleep.” their own failings (Chuick et al, 2009). that the time around the delivery poses a He found the disclosure cathartic and Although they may know that their con- risk to the mental health of the father was able to discuss his fears at length. duct is unacceptable, they may find it dif- (Stramrood et al, 2013). Empathetic staff listened to him and ficult to admit it, either because they do Box 1 features the case of a man who assured him he would be kept informed not know how to express their emotions or developed PTSD after witnessing the birth at all times during labour and delivery.