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Nursing Practice Keywords Antenatal clinics/Childbirth/ /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 , 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 , others anger and guilt. 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

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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. because they think it is a sign of weakness of his child. He discussed this further with a PTSD to do so (Garfield et al, 2010; Wexler, 2009). therapist. After several sessions with the To combat feelings of inadequacy or fra- Postnatal period PTSD specialist he felt able to manage gility and emphasise their independence, Paternal postnatal depression is increas- his distress and became more confident some resort to escape in video games, ingly recognised but has not been exten- about the impending birth. surfing the web or overworking. Their

ALAMY sively quantified. Current statistics show resentment may degenerate into antisocial

Nursing Times [online] December 2017 / Vol 113 Issue 12 27 www.nursingtimes.net Copyright EMAP Publishing 2017 This article is not for distribution Nursing Practice Discussion behaviour or self- with alcohol (Bosanquet et al, 2015), but there are no (Lobato et al, 2012). Exploring positive self- or illicit drugs, which may in turn precipi- obvious reasons why they could not be regard – a psychological prerequisite for a tate domestic violence and abuse (Paulson used for them. healthy mind – can help him achieve his and Bazemore, 2010; Wexler, 2009). The Edinburgh Postnatal Depression full potential. Encouraging and sup- Many fathers’ mental health disorders Scale (EPDS) has been used globally for porting him to engage with his child can remained undiagnosed because paternal mothers and has been validated for fathers. help expel the doubts he may have about depression often fails to manifest through Simple and user-friendly, it encourages his fathering skills. the classic or overt symptoms described in the professionals to delve deeper into the There are therapeutic interventions the Diagnostic and Statistical Manual of reasons why a parent may have low mood that some find helpful. The most common, Mental Disorders (American Psychiatric (Edmondson et al, 2010; Cox et al, 1987). which is available as a web-based , Association, 2013). Surrey Parenting Education and Sup- is cognitive behavioural therapy. This Studies have noted a strong influence of port and the Fatherhood Institute have examines life situations and difficulties, the father on the infant, particularly if the developed a tool for evaluating and sup- explores the reasons for any negative father is depressed. Depressed fathers tend porting the mental health of new fathers thinking and behaviours, and attempts to to be more hostile and passively aggres- (Bit.ly/FatherhoodTool). replace them with more positive responses sive, and are often less attentive to the Discussion and listening helps both (Carter et al, 2015). infant’s needs. This threatens the infant’s mothers and fathers understand any mood Mindfulness can also help. It is a secure attachment, which is associated, in disorder and can encourage them to thought process that allows individuals to turn, with an inability to interact socially express a need for further support. As with focus their attention on their immediate and a lower cognitive development later in all assessment tools, health professionals thoughts, sensations, sights, sounds and life. When both parents are depressed, the need to be trained in listening and inter- smells, encouraging them to be in the pre- consequences for the wellbeing of the pretation skills to ensure they use the tool sent and not dwell on the past or worry infant can be even more severe (Ramchan- correctly and to its full potential. about the future (Bajaj et al, 2016; Parent et dani et al, 2011). al, 2016). Social media usually convey playful Management strategies Referral to medical services should images of positive relationships between The transition to fatherhood can be com- always be considered for psychopharma- fathers and their newborn children. How- plex and demanding, and take its toll on ceutical . ever, some fathers did not experience this the most resilient of men. At no stage may be prescribed for more severe forms in their own childhood, lacked a father role should health professionals assume that of depression. A combination of medica- model or experienced an abusive relation- fathers are fully able to cope (Singley and tion and therapy can have positive results ship. Images of ‘good dads’ only compound Edwards, 2015). Actively listening to iden- (Isaacs, 2017). Contact with support groups their feelings of inadequacy, leading them tify a father’s mental health needs and (Box 3) has also been found to be beneficial. to question whether they are the ‘good- signposting him to the appropriate ser- Whatever the choice of treatment, it enough fathers’ that society expects. vices will help engage him. It is possible will not be immediately effective. Fathers Box 2 features the case of a man with that he has not confronted his own anxie- need to be patient and not expect too much postnatal depression. ties, so allowing him to explore them can too quickly but allow the treatment to take be cathartic. Explaining the possible link its course. This will help them understand Assessment tools between feelings of distress and a drinking their condition, recognise early warning The perinatal period offers a prime oppor- habit or a tendency to overwork can help signs and prevent reoccurrence. tunity for health professionals to assess him understand his avoidance behaviours. Fathers may be reticent to engage with the mental health of both parents, but Exploring his diet and patterns health professionals, whose input used to fathers’ mental health is often neglected. can determine his level of depression be reserved for mothers and who may be Some professionals may enquire about their mood or attitude towards the birth, Box 2. Case study: postnatal depression but there is little evidence of more robust enquiries. There are assessment tools that A young man was surprised when his partner told him she was pregnant, but have been validated for use with fathers, gradually accepted the situation. As the pregnancy progressed he felt increasingly but anecdotal evidence suggests they are anxious, particularly about the financial implications and the lack of freedom. The not widely used, primarily because the relationship with his partner deteriorated significantly after his son was born. He father is either not present when the health tried to cope with his feelings of anger and despair, until a health professional noted professional visits or are reluctant to par- his low mood, giving him an opportunity to confide in someone. He first described ticipate (Wendt and Shafer, 2016). psychosomatic pain, but after further exploration agreed that he was probably Since the National Institute for Health experiencing paternal depression. and Care Excellence published its clinical He commented: “It was only after speaking to you that I understood why I was guideline 45 on antenatal and postnatal drinking too much. I was getting more depressed after feeling out of place and mental health in 2007 (which has since thinking I was going to be a rubbish dad. I just found it easier to stay at work longer been replaced by clinical guideline 192 and then went to the pub. Doing that made me feel like a real man again.” [NICE, 2014]), the Whooley questions This opportunity to confront his thoughts and feelings enabled him to understand (http://whooleyquestions.ucsf.edu/) have how they influenced his behaviour. His GP prescribed him an and been widely used for assessing mothers’ referred him for counselling. He was able to access useful websites and gained the mental health in the perinatal period. They confidence to seek out support services. have not been validated for fathers

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considered intrusive. A comprehensive References Box 3. Resources on paternal knowledge of paternal mental health will Alexander GM (2014) Postnatal testosterone concentrations and male social development. mental health help to break down barriers. Health profes- Frontiers in Endocrinology; 5, 15. sionals also need to recognise their own American Psychiatric Association (2013) l The NHS Choices guide to stress, limitations and know when to refer Diagnostic and Statistical Manual of Mental anxiety and depression: patients. There is no ‘one size fits all’ and, if Disorders, 5th edn. Arlington, VA: APA. Bit.ly/NHSChoicesAnxietyDepression Bajaj B et al (2016) Mediating role of self-esteem there is no significant progress, health pro- on relationship between mindfulness, anxiety, and l Fathers Reaching Out: fessionals can feel impotent. A father’s con- depression. 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