Paternal Postpartum Depression

What Health Care Providers Should Know

Anna K. Musser, MS, RN, CPNP; Azza H. Ahmed, DNS, RN, IBCLC, PNP; Karen J. Foli, MSN, PhD, RN; Jennifer A. Coddington, DNP, MSN, RN, CPNP

Disclosures

J Pediatr Health Care. 2013;27(6):479-485. 

In This Article

Role of the PNP in Managing Paternal PPD

The PNP plays a critical role in family health promotion in all settings, but especially in the primary care setting. PNPs are in an excellent position to prevent, educate, screen, and refer patients to appropriate resources when needed. These principles are the cornerstones of practice for PNPs.

Prevention and Education

Anticipatory guidance may be one of the most important aspects of care for PNPs to incorporate in their practice when they are working with expectant and new parents. Dennis and Chung-Lee (2006) found that education about PPD was a major help-seeking facilitator for women, and this finding may very well hold true for men. As previously stated, paternal PPD is associated with higher community care (outpatient or primary care) costs, which demonstrates the need for more research concerning cost-effective prevention and treatment options (Edoka et al., 2011).

Goals of parent education include increasing awareness and decreasing the potential stigma associated with paternal PPD. Prenatal and obstetric examinations, expectant parent visits, the birth hospital stay, and newborn and infant well-child checkups all provide ideal opportunities for the PNP to educate both parents about PPD (Box 1). The PNP also may direct fathers to credible online professional resources. Involving both parents promotes managing depression as a family unit rather than limiting the focus to one parent, which may help to facilitate better engagement in treatment if needed (Nazareth, 2011). Fathers are likely aware of maternal PPD; however, they may not be aware that they are at risk for the condition themselves (Nazareth, 2011). Providing anticipatory guidance such as signs, symptoms, and risk factors may help fathers recognize their new feelings after the birth of their baby and know when to seek help. Verbal education and discussion, brochures, handouts, posters in examination rooms, and including paternal PPD in hospital discharge instructions are potential avenues for providing education or screening (Box 1).

Depending on the setting and situation, the PNP may only have the opportunity to work with the mother. The father may not be present for prenatal examinations or for infant well-child checkups when the PNP may assess for maternal PPD. In these cases, it would be important for the PNP to speak with the mother about the signs and symptoms of paternal PPD and assess for any concerns she may have about her partner. Equipped with the knowledge that both mothers and fathers may experience PPD, the mother may be able to secure assistance or further screening for her partner if symptoms are identified.

Common problems experienced by many fathers during the postpartum period include frustration, feeling that they do not have enough time with their infant, deterioration of their lifestyle and sexual relationship with their partner, a restricted sense of freedom, and not feeling skilled in infant care (Genesoni & Tallandini, 2009). The transition to fatherhood can be an extremely stressful time for men (Halle et al., 2008). Early symptoms to assess for include persistent feelings of powerlessness, moodiness, irritability, anxiety, frustration, and a negative perception of self (Genesoni & Tallandini, 2009). Fathers should know that they are at highest risk for depression at 3 to 6 months after the birth of the baby (Nazareth, 2011; Paulson & Bazemore, 2010).

Assessment

Signs and Symptoms Although no standardized guidelines currently exist, the PNP usually has several opportunities, as previously discussed, to assess both parents for depressive symptoms and risk factors for PPD. PNPs may quickly assess both parents and formally screen for symptoms if indicated, which would involve incorporating an assessment of parental mental health status into well-child examinations. Again, the greatest risk factor identified thus far for paternal PPD is maternal PPD (Goodman, 2004; Kim & Swain, 2007; Wilson & Durbin, 2010). This risk factor stresses the importance of assessing both parents for PPD.

The PNP should be aware of the identified characteristics of paternal PPD ( Box 2 ). Paternal PPD differs from maternal PPD in several ways; the condition has a more insidious development and less obvious symptoms, which make it more challenging to identify (Kim & Swain, 2007; Wilson & Durbin, 2010). Depression in fathers tends to begin later, often after the onset of depression in mothers, with the rate increasing throughout the first postpartum year (Goodman, 2004). Fathers may withdraw from social situations and present with indecisiveness, cynicism, avoidance, anger attacks, affective rigidity, self-criticism, and irritability (Kim & Swain, 2007; Schumacher et al., 2008).

Negative parenting behaviors such as decreased positive emotions, warmth, and sensitivity and increased hostility, intrusiveness, and disengagement may be observed (Wilson & Durbin, 2010). Alcohol and drug use, increased marital conflict, and partner violence are also signs of male depression (Kim & Swain, 2007; Schumacher et al., 2008). PNPs also should be aware of somatic symptoms such as indigestion, changes in appetite and weight, diarrhea, constipation, headache, toothache, nausea, or insomnia (Kim & Swain, 2007; Schumacher et al., 2008). Depression in new fathers also may be difficult to identify because depressive symptoms may be interpreted as natural anxieties concerning changes in social and financial conditions (Schumacher et al., 2008).

A thorough history is an important component. When assessing paternal PPD, risk factors to look for include an established history of depression, young fathers (younger than 25 years), lower socioeconomic status, working class occupations, men belonging to step-families, partners of single mothers, inadequate support systems, and maternal PPD (Goodman, 2004; Nazareth, 2011).

Screening Recommendations and Techniques To date no diagnostic tool has been developed to exclusively screen for paternal PPD. However, the PNP may use the DSM-IV-TR criteria for depression, the Patient Healthcare Questionnaire-2 (PHQ-2), the Edinburgh Postnatal Depression Scale (EPDS), or the Center for Epidemiologic Studies Depression Scale (CES-D) to aid in the screening process (Cox, Holden, & Sagovsky, 1987; Radloff, 1977). The PNP may easily download any of these scales for free from the Internet.

The DSM-IV-TR criteria for a major depressive episode include five symptoms (from a list of nine) that must be present for at least 2 weeks (American Psychiatric Association, 2000). At least one of the symptoms must be depressed mood or loss of interest (American Psychiatric Association, 2000). Other symptoms include a significant (greater than 5%) weight loss or gain or an increase or decrease in appetite, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or inappropriate guilt, diminished concentration or indecisiveness, and recurrent thoughts of death or suicide (American Psychiatric Association, 2000).

The PHQ-2 is based on the DSM-IV-TR criteria and is a reliable tool for quickly assessing for the presence of depression in fathers (Kroenke, Spitzer, & Williams, 2003). This screening tool utilizes two screening questions based on the frequency of depressed mood and anhedonia within the past two weeks (Kroenke, Spitzer, & Williams, 2003). If the patient screens positive on the PHQ-2, the PNP may further screen with the Patient Healthcare Questionnaire-9 (PHQ-9), which features nine questions, or refer the father to appropriate mental health services (Kroenke et al., 2003).

The EPDS is a 10-item self-report questionnaire that has been validated and widely used (Cox et al., 1987). Eight questions address depressive symptoms such as laughing, enjoyment, and guilt. Two questions address anxiety symptoms such as feeling worried and panicky. The responses are scored on a scale from 0 to 3, with 3 being the highest severity of the symptom. In women, scores of 12 or more identify the possibility of a diagnosis of a depressive disorder (Cox et al., 1987). A score of 12 often is used as the cut-off score for depression in men; however, a lower cut-off score is sometimes used because of the different presentations of depression in men and women (Kim & Swain, 2007).

The CES-D short form measures symptoms such as affect, somatic symptoms, psychomotor retardation, and interpersonal activity (Radloff, 1977). The test consists of 12 items, compared with the 20 items on the full CES-D, which are scored on a scale from 0 to 3, with 3 indicating the highest severity (Radloff, 1977). A score between 10 and 14 is suggestive of moderate depression, and scores greater than or equal to 15 suggest severe depression (Radloff, 1977). As with the PHQ-2, PHQ-9, and EPDS, this tool can only be used to screen for depression and should be followed by a diagnostic evaluation.

Management

The recognition of how to engage with men and support their needs as fathers is in its infancy (Halle et al., 2008). General evidence-based practice for treating depression in men would indicate the benefits of pharmacological or psychological therapies (Nazareth, 2011). However, the evidence for these treatments for paternal PPD and the effects on child outcomes require further study (Nazareth, 2011). For the most effective treatment plan, interventions should be focused on the suspected cause(s) of the father's depression (Box 3; Nazareth, 2011). For example, if impaired parenting is the mechanism through which paternal depression affects children, then the treatment plan should focus on enhancing positive parenting skills. If a low mood leads to poor engagement with their child, then antidepressant or cognitive behavioral therapy may be appropriate (Nazareth, 2011).

To help fathers cope with the initial stressors of becoming a new father, PNPs may suggest parenting classes that teach ways to recognize infant needs and assist the father in learning to provide physical care to their infants, including feeding and changing diapers. Research has shown that fathers may cope by learning to "take control" of a situation. Empowering fathers to acquire baby-care skills promotes self-confidence and decreases frustration (Genesoni and Tallandini, 2009).

Social and emotional supports are also crucial components in the management of emotional distress and mental illness (Halle et al., 2008). Therefore interventions that target the couple and focus on promoting a positive partner relationship may be beneficial (Dennis & Letourneau, 2007). Some fathers believe that they have very little support beyond what is provided by their partner and even less support if their partner is also experiencing PPD (Halle et al., 2008). This situation is an opportunity for the PNP to act as another resource of support for both parents. PNPs should be accessible, open, and encourage the discussion of the new father's feelings (Halle et al., 2008).

Dennis and Letourneau (2007) studied the effects of support and the development of PPD in women and discussed the importance of postpartum support groups. They suggested the implementation of support groups to specifically target PPD and the challenges in the postpartum period as a treatment option or form of secondary prevention (Dennis & Letourneau, 2007). The implementation of postpartum support groups for fathers may be efficacious as well.

Increasing postpartum partner support and marital satisfaction may be an important goal in implementing interventions for PPD. Matthey, Kavanagh, Howie, Barnett, and Charles (2004) found that participants experienced higher partner awareness of maternal feelings and satisfaction with sharing home and infant tasks at 6 weeks postpartum than did couples who did not participate in educational sessions that discussed hypothetical situations.

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