What is the Impact of Paternal Depression on the Family?

I. Background of the Issue: 

Postpartum depression is a major concern in the US affecting many families. Paternal depression is often excluded when dealing with growth and development: effects on the child. This aspect of paternal postpartum depression is essential to bring awareness to a disorder that providers fail to address. According to Charandabi et al (2017), there has been an increased prevalence of fathers experiencing postpartum depression symptoms. Approximately, 4-13% of new father suffer from postnatal depression and with little to no support provided for fathers. Postpartum depression is a psychological disorder that is thoroughly screened and communicated to mothers, but poorly educated and unscreened by clinicians to fathers. From 1980-2009, the epidemiology of depression in fathers has until now been discussed in relatively few studies. Kaplan, Dungan & Zinser, (2004) asserts that Paternal Postpartum Depression Postpartum depression is considered a maternal phenomenon, and most research about postpartum mood disorders centres on new mothers. But fathers can and do experience these issues as well. 

A recent study in the journal Couple and Family Psychology: Research and Practice followed 199 couples whose child was 4.5 months old at the postpartum evaluation and 45.5 months at the toddler evaluation. Each parent separately filled out a questionnaire about his or her mood and child's behaviour. Study’s outcome suggests that postpartum depression in dads is present and can affect children's behaviour and emotional health just as much as mom's postpartum depression (Escribà-Agüir & Artazcoz, 2011). This project will be a comprehensive literature review to provide evidence-based information on the harmful effects of a lack of education provided to new fathers on postpartum depression. The focus will be on the period of when the screening and education were provided for postpartum depression. The goal is to bring awareness to the community of a disorder that is known but poorly studied that affect many families. The community is not aware of the impact of depression on fathers during postpartum. This paper will bring awareness of the issue of paternal postpartum depression to the community with the effort of developing education and having readily resources where fathers facing postpartum depression and their family can be supported and educated. 

II. Objectives 

It is evident that maternal depression is well-known and studied mental disorder, however; paternal depression is excluded when dealing with growth and development. This aspect of paternal postpartum depression is essential to bring awareness to a disorder that providers fail to address. The paper will assess the relationship between paternal depression/anxiety and the impact on the family. Further, the paper will bring awareness of the issue to the community with the effort of developing education and having readily resources where fathers facing postpartum depression and their family can be supported and educated. Therefore, the primary objective of this document is to bring awareness to the healthcare community of a disorder that is known but poorly studied and affects many families, paternal postpartum depression. For instance, understanding various management strategies, understanding when one should seek help, exercises, modifying environments and differentiating between treatments 

III. Inclusion Criteria 

The inclusion criteria adopted for the study was critical to ensure that the researcher only obtains the right data and information for the research and also saved on time that would have been spent on gathering irrelevant data. In this case, the inclusion criteria focused on the types of participants as follows: adulthood (18 years and older), adoptive/foster families, effects of smoking and perinatal depression and impact of alcoholism and depression. Other factors were children of depressed persons and families of childbearing age, foster/adoptive families who have been impacted by perinatal/postpartum depression. Further, the participants entailed those diagnosed with at least one of the Perinatal/postpartum depression, including paternal depression, maternal depression, anxiety, stressed, history of mental illness and or low economic support. Others included any anatomic location. Others factors were being undertreated within primary or tertiary settings, such as in the OB/GYN office, clinic, community, home and hospital, child development related to parental bonding, those receiving care that is typical to a geographical location that is not part of an experimental study. Additionally, inclusion criteria entailed those studies that used one or two instruments Edinburgh Postnatal Depression Scale or PHQ-9. 

Exclusion Criteria 

The exclusion criteria helped the researcher to eliminate irrelevant articles and participants who would not have contributed towards the success of the study. It thus helped save time and money by only focusing on what is believed to be essential to respond to the research question. Based on the types of studies, the exclusion criteria entailed non-English languages, published pre 1998, grey literature / not published in peer-reviewed journals and literature only available online, published abstracts. Further, studies using the following methodologies were also excluded, studies without a sampling procedure, any study where qualitative data not analyzed such as continuous data, case report, treatment guideline document or even a commentary article, written to pass a particular view or aimed at stimulating research but lacks research element. On the part of the participants, the following were used as the exclusion criteria: non-childbearing families, families who have experienced loss (fetal death, stillborn or infant death before 12 month period and no Perinatal/postpartum depression diagnosis. Other exclusion criteria were the diagnosis of depression related to loss (stillborn or infant mortality before 12 month period) and the middle-aged Adults > 60. 

IV. Search Methods 

In the search method to collect the information to respond to the research question, the following electronic databases were accessed: 

-CINAHL Searched dates 06/11/2017 

-EBSCOHost searched dates 06/20/2017-6/22/2017 

-Medline searched dates 06/11/17-06/13/2017 

-PsycINFO Searched dates 06/20/2017 

-PubMed Searched dates 06/11/2017 

-Academics Search Complete 06/21/2017 

V. Review of Literature 

a. History of Maternal and Paternal Depression 

Melancholia which is a serious depression experienced when the mother has successive childbirth was for the first time illustrated by Joao Rodrigues de Castelo Branco in 1551. Later in 1950, psychiatrists’ attention shifted to milder and common disorders like postpartum depression. According to Direct (2002), the maternal depression between infancy after four years is defined by the dysphoric mood in various variation, somatic features and impaired mentation. Such a description evidently pays much stress on the postpartum depression on mothers but overlook the potential influence on the dynamic system of the family. Currently, maternal postpartum depression is a systematic illness that affects the wellbeing and relationship with the children and the husband (Kaplan, Dungan & Zinser, 2004). Traditionally, postpartum depression was considered as women’s disorder despite it affecting men. Due to the lack of c continuous evaluation criteria for paternal depression, it follows that its symptoms might be misconstructed. Arguably, men’s affect might significantly present more like anxiety and anger than just sadness. Some of the hallmark signs of the male depression include extra-marital affairs, avoidance behaviour, withdrawal, and an irritable mood and partner violence. 

b. Risk Factors 

Studies have identified various causal factors for paternal and maternal postpartum depression. For the mother, the following are the major causal factors for maternal depression, marital problems, and personal history of depression, poor quality of life, maternal antenatal depression, low social support and even low marital relationship satisfaction. According to a study by Crockenberg & Leerkes, (2003), infant-related problems such as sleeping problem is connected to both maternal and paternal level of depression. The father’s postpartum depression mostly originates from neuroticism and substance abuse. 

The previous history of severe depression of the fathers together with high prenatal symptom rates for depression intensifies their rates of depression (Letourneau et al., 2009). The study further established that lower levels of satisfaction in their relationships contribute to the paternal depression. Also, men with the wives who might be experiencing elevated depressive symptoms are more likely to develop postpartum depression. According to a study by Madsen & Burgess, (2010), there were more postpartum depression symptoms among the fathers whose partners were shown to be depressed. 

Majority of the low incomes new fathers have further been shown to be highly vulnerable to postpartum depression as a result of the interacting factors. Among the low-income African American in a study by, Anderson et al., (2005), 56 percent of all these fathers were confirmed to have significant signs for postpartum depression which apparently indicated cause for greater clinical concerns. Some of the primary sources of their depression included problems with drugs, criminal conviction history and permanent housing challenges. Arguably, higher levels of social support were primarily related to higher depressive symptomatology for low-income fathers as a result of the assumed cost of reciprocity which ultimately prevents them from making use of the available social support (Anderson et al., 2005). In addition to this, the more tenuous the relationship of the father is to the mother of their child, the more probable it is that these fathers will experience postpartum depression. 

c. Attached Stigma 

Goodman (2004) posits that paternal postpartum depression is associated with aspects of stigma. Majority of the fathers often get the societal message that they are expected to be overjoyed with happiness. However, this tends to make it challenging for such group of the new fathers that feel highly anxious and depressed. Paternal postpartum depression is mostly associated with mental illness thus attracting the significant level of stigma. It is evident that depressive fathers tend to experience levels of stigma and this has had negative consequences on their psychosocial through expected and experienced discrimination. Chang, Halpern & Kaufman, (2007) posits that the depressed fathers might expect various stigmatizing reactions in every sphere of life including at work, school or in the community. Therefore, they tend to spend the considerable part of their time concealing their postpartum depression. Further, the stigma often forces depressed fathers to withdraw from both economic and social functioning. The experiences of stigma often push men not to seek treatment. It is critical for the new fathers not to allow stigma concerning mental health to keep them from accessing the needed help. 

d. Cultural Aspect 

People are primarily controlled by the set of regulations defined by cultures which apparently shape and influences their behaviour. Consequently, various cultural elements of an individual’s social system have the consequence of a person’s emotional life. Some of the primary cultural differences that are believed to influence paternal postpartum depression include social stresses, family structures, socially –allowed defence strategies and rituals (Kaplan, Dungan & Zinser, 2004). Other cultural factors that are believed to be critical for clear comprehension of paternal depression are the information exchange among individuals related to postpartum depression, the distinctive language associated with postpartum depression and certain beliefs concerning healthcare. The rates of prevalence of the postpartum depression tend to vary significantly from one culture to another. Postpartum depression thus occurs three times more in the developing countries compared to developed nations (Lamb & Lewis, 2010). 

e. Mental Health Consults/ Counselling 

Counseling is an effective therapy to address how fathers are feeling, thinking, and acting. For the parents reported to be struggling with postpartum depression can significantly benefit from learning new ways to cope with postpartum depression (Condon, Boyce & Corkindale, 2004). Counselling for paternal postpartum depression offers an efficient outlet for sufferers to share their thoughts and feelings to obtain help from a professional therapist. Majority of the literature on the paternal postpartum depression address the notion that factors like attitudes and perceptions towards paternal depression in diverse cultures might influence help-seeking behaviour. Individual counselling in most instances focuses on an individual’s immediate or even near future depression concerns. Escribà-Agüir & Artazcoz, (2011) points that a specialized psychological therapy like Cognitive Behavioural Therapy is utilised to help guide depressed fathers through their problem. Therefore it enables them to understand the nature of their postpartum depression and way to efficiently change their thoughts and behaviours to reach a full potential and at the same time learn ways to enjoy the joy of being a father. Therefore counselling for the postpartum depression will enable the new fathers to feel much comfortable to open up concerning their illness without being judged or ashamed. 

F. Depression and its Effect on the Children 

Recent studies have established that the fathers’ postpartum depression can impact negatively on their children in infancy through 4 years of age. Based on research by Davey, Dziurawiec & O’Brien-Malone, (2006), there was a severe postpartum depression in fathers related to higher rates of behavioural and emotional issues among their infants especially the male children of age 3.5 years. In addition to this, the most severe consequences were experienced when these dads were reported to be profoundly post-natally and pre-natally depressed. 

Postpartum depression of the fathers apparently risks relationship’s quality between the new father and mother. According to Dave et al., (2005), a higher quality relationship between couples has been intimately connected to decreased child fussiness level. Research has also shown that the parental and marital depression is linked with a higher adjustment challenges among kids (Cummings et al., 2010). 

In their study, Escribà-Agüir & Artazcoz, (2011) established that dads diagnosed with elevated postpartum depression tend to be less engaged with the infants. Stress evidently affects the father’s level of attachment with the infants. On the other hand, the poor father-child attachment is associated with problems children’s peer relationships. While the father’s psychological well-being is positively linked to the parent’s sensitivity, the father’s postpartum depression arguably seem to limit their capability to parents these children much efficiently. 

Fathers experiencing postpartum depression have been reported to be less likely to tell stories, read and even sing songs to their babies comparable to the fathers who are not depressed. This apparently explains reasons why father’s postpartum depression has the negative impact than that of the mothers on the child’s language development. In most instances, postpartum depressed dads always will utilize a voice with a flatter tone when they are interacting with their four-month-olds, and this is connected to their infants’ cognitive delay (Huang & Warner, 2005). 

H. Delayed Bonding 

According to Holopainen (2002), paternal postpartum depression is closely related to delayed bonding between the father and the children. Late bonding is a collective experience and mostly occurs for various reasons such as postpartum depression. In most instances, the fathers tend to have less interest and energy care for the child. Father’s postpartum depression arguably tends to compromise the dad’s capacity to mutually control and manage the interaction, through two interactive patterns, intrusiveness or withdrawal (Fisher et al., 2015). On the one hand, intrusive fathers often display hostile effect which apparently disrupts the overall activities of the infants. Therefore, as a result of the postpartum depression, infants will experience higher levels of anger, turn away from the father with the aim of limiting his intrusiveness and internalize an angry and highly protective coping style. According to Holopainen (2002), the majority of the withdrawn fathers have further been shown to be unresponsive and disengaged, and often, they do absolutely nothing or little supports the activities of the infants. In such a case, the children are not able to efficiently cope or even to self-regulate such a negative state and in the process develop passivity, withdrawal and even self-regulatory behaviours such as sucking on the thumb. 

i. Group Support, Resources and Education 

Though seldom discussed, paternal postpartum depression has become common thus inspiring numerous support groups. Some of the key resources available for the new fathers include helpline for non-profit agencies that readily offer social and physical support to the depressed fathers with children of ages five and below. There are licensed marriage and family therapist that plays a critical role in facilitating empowering new fathers with skills and knowledge of parenthood. Further numerous support groups for fathers have emerged and majorly targets fathers with children below the age 5. Therapy group also have been useful to the new fathers regarding managing their postpartum depression (Grube, 2004). In these therapy practices, the staffs work with new fathers assuring them that what they are experiencing is normal. Childbearing couples are currently attending childbirth education classes which have helped the new fathers. The young couples are more technologically savvy and can easily access various alternatives to education via the internet aimed at addressing the post-partum depression. Childbirth educators have further significantly modified their curricula to efficiently support the cultural and social changes of childbearing with regards to postpartum depression. Educational strategies help the new fathers to understand ways to meet their need as a parent thus improving their overall state of mental wellness (Goodman, 2008). 

J. Motivational Strategies/Breaking the Silence 

There are also diverse motivational strategies that have helped the new fathers who are experiencing post-partum depression. The new fathers are motivated to break their silence through providing them with vital educational help that enables them to understand the early signs and symptoms of postpartum depression. According to Jorm et al., (2003), the new fathers in most cases might not wish to admit to having the post-partum depression symptoms; therefore, it is critical to adopt the motivational strategies aimed at encouraging them to seek help as soon as possible. Postpartum depression is evidently hard to talk about given the stigma that apparently surrounds the condition. The new fathers should be encouraged to speak out and break the silence, and this would be possible by informing them that post-partum depression is a normal condition that majority of the new parents go through (Grossmann et al., 2002). The first step is to understand his postnatal depression and how it affects him. The next step is to encourage the new father to acknowledge his depression as a condition that has to be addressed just like any other illness. A self-care is of great importance, and this should be followed by involving the professional. 

K. Monitoring/Assessing the Condition Early in the Pregnancy, Implementation Treatment Options 

Research has established assessing the condition early in the pregnancy is one of the most suitable strategies towards efficient management of the post-partum depression. Antenatal period, intrapartum support, early postpartum checkups in addition to continuity of care are critical for the implementation of practical treatment option. Through early screening, the condition will be detected early enough and then monitored over time for effective implementation of suitable treatment (Grube, 2004). Postpartum debriefing and continuity of care in the postpartum period in addition to social support in the postpartum period are essential and must be considered when developing a suitable treatment strategy. When the new fathers learn concerning early warning of paternal post-partum depression, they will be able efficiently to assess and even notice potential changes and encourage them to seek treatment and other suitable help. 

VI. Results 

Summary of evidence 

Researchers also found that for both moms and dads, postpartum depression often predicted future depression and interpersonal conflict, associated with anxiety and behavioural issues in their toddlers. Based on the idea that the studies on the new father’s postpartum depression are still in its infancy, its overall understanding has significantly improved within the last ten years (Howard et al., 2003). Studies have further established that the first time fathers are more prone to depression with mild to moderate depression, however; there is no apparent rise in severe mental disorder. 

According to a meta-analysis by Buist, Morse & Durkin, (2003), they found that about 10.4% of fathers are depressed both pre- and post-natally, with the peak time for fathers’ depression being between three and six months after the birth. Pregnancy period is an intense period of a greater level of stress for the new dads than the post-birth period. Research has pointed out that the rates of the dad’s postpartum depression are higher immediately once the child has been delivered than before the delivery (Huang & Warner, 2005). Based on an empirical research by Howard et al., (2004), it was established that there were no pre- post-birth depression differences; however, dad’s depression levels postnatally occurred at the eighth week. 

The evidence that seemingly impaired Postpartum mental health has been established to have an adverse impact on the infant in various aspects including cognitively is extensive, emotionally, behaviorally and socially. Father’s depression is linked to the personality, partner-related in addition to the infant-related factors. Kurstjens & Wolke, (2001) asserts that the partner-related element is comprised of the poor relationship with the mother and inadequate practical and emotional support from the father. Studies have pointed out that the functioning of the father as a support person is critical based on the fact that depressed new mother is more likely to turn to their partners than to any other person such as the medical staff but when the father is going through depression, this might not be possible. Research has shown that in the contemporary world, 70 percent of the new mothers often turn to the father’s of their babies for emotional support compared to 47 percent in 1960 thus emphasizing the importance of the father. 

Limitations 

Our search of the literature led to the findings of many flaws, such as the studies used a smaller population size of about 30 men of ages between 22 years and younger and 40 men of ages 40 years and above, and in the process not allowing for further division of the younger and older age groups. The father’s depression levels were not clinically significant, but they were representative of scores one would expect in the general population of fathers of young children. Further, it might be the case that high rates of couple conflicts might results in an intense depression in either parent, instead of being the outcome of depression. Lastly, healthcare professionals are currently using adequate measures in detecting depression in this unique population. 

Postpartum depression is a significant concern and occurs among the new parents immediately after the child has been born. Based on the above analysis, it is evident that the symptoms of postpartum depression seem to be closely related to depression. Maternal depression is well-known and has been studied over the years as it affects the whole family. Paternal depression is often excluded when dealing with growth and development and its effects on the child. This aspect of paternal postpartum depression is essential to bring awareness to a disorder that providers fail to address. Paternal depression is mainly characterized by irritability, sleep changes, hopelessness feeling, self-loathing and loss of energy that further lead to other detrimental consequences to the children. Children-parent attachment is essential to child development. “Studies show a link between paternal depression and a new father’s state of mind concerning attachment”. Poor paternal-infant attachment is directly related to poor child development. Ghate, Shaw & Hazel, (2000) claim that paternal -infant attachment enhances infant outcome. Being a father is often very overwhelming to many women. Negligent parenting may result if there is no attachment between the parent and infant. Negligence poses increase health risk for the child. Besides, depressed women may respond to their infants with increased withdrawal and hostility making the child at risk for child abuse. Consequently, child abuse may cause trauma that may affect the child’s lifelong psychological and cognitive health. 

Vii. Presentation of Results 

Based on the above analysis, it is evident that the postpartum period, particularly for the new fathers, is related to the diverse adjustment that seemingly leads to the depression risks. Fisher, Wynter & Rowe, (2010) claim that paternal postpartum depression arguably can cause negative behavioural and emotional consequences to the entire family especially among the children. Those dads associated with higher rates of the ecological risk factor, for instance, lack of social support, the stress of being a parent and being excluded from the bond between the mother and child have higher chances of developing postpartum depression. 

The infants of the postpartum depression fathers have further been confirmed to show a specific trend of deregulated arousal and attention. In an empirical research by Davey, Dziurawiec & O’Brien-Malone, 2006), cognitive performance was shown to much worse for the infants of the post-natally depressed dads. Most of the depressed fathers are less probable to offer what has been considered as child’s contingent stimulation, and this ultimately affects their overall performances on various non-social tasks. In addition to this, another factor is the adverse effect indicated by the children of the depressed fathers even in a situation where they might be interacting with non-depressed adults. Studies have also reported that a child’s adverse effect interfered with learning and capability to process specific information. 

Postpartum depression among fathers often shows less level of responsiveness and attentiveness to the needs of their children. These fathers are considered as poor models for the negative mood regulation and control in addition to problem-solving. According to Jorm et al., (2003), the depressed postpartum fathers are less probable to set specific limits on the infants and at the same time track them against the set limit. Majority of the children of these depressed fathers often appear to be passively non-compliant. Therefore, these children were rated by their dysphoric mothers as being highly vulnerable, and further, they have more internalizing (depressed) and externalizing problems (aggressive), that are apparently related to lower interaction ratings. These children were also more probable to respond negatively to all forms of friendly approaches, likely to engage in low-level physical play. Such aspects of the child’s behaviour were also related to postpartum depression even when taking adverse events like demographic variables and even marital conflicts (Edhborg et al., 2003). 

Majority of the studies have agreed on negative consequences of the paternal depression on the infant’s cognitive growth. In addition to this, early experiences with insensitive maternal relationship seemingly appear to be highly predictive of poor cognitive functioning (Grossmann et al., 2002). It is true that boys seem to be highly sensitive compared to girls to the effects of the father’s illness. There is a reduction on the standardized tests of the intellectual attainment particularly reasoning concerning analogies and even opposites. Research has also shown that these children tend to display weak adaptive functioning such as externalizing and internalizing problems. The children of the depressed fathers have further been reported to be at a higher risk of psychopathologies, such as affective, anxiety and conduct disorders. 

Ghate, Shaw & Hazel, (2000) note that there is a relationship between the attention deficit disorders among the children and paternal mental health. In various longitudinal studies, lower IQ scores, special educational needs, attention problems and even difficulties in mathematical reasoning were more prevalent among kids whose fathers were depressed at about three months postpartum. Further, boys are profoundly affected compared to the girls. Conversely, academic challenges among kids of these fathers are not mediated by IQ of the parent, fathers’ mental health after the postpartum depressive episode or even socio-demographic variables. 

IV. Discussion / Application to Advanced Nursing Practice 

Bronte-Tinkew et al., (2009) asserts that early and continuous screening and referral for the new father treatment by a qualified by paediatricians during the postpartum period has been critically analyzed. Majority of the intervention programs for the paternal postpartum depression often has focused on the provision of the pharmaceuticals, psychotherapy and psychosocial support. The Family Nurse Practitioner (FNP) plays a crucial role in promoting the health of the entire family within a primary care setting. They often play a vital; role in co-managing the patient’s conditions with other specialists and offers a case management for various long-term illnesses. FNPs have a fundamental role to play to improve the social health of their patients through preventing diseases, educating the patient, screening, and referring these patients to proper required resources (Brockington, 2004). FNPs have the capability of working with broader patient population irrespective of ages, gender and life stages and they form the basic principles of FNPs practices. The existence of birth hospital stay, expectant parent visits, infant checkup and even Prenatal and obstetric examination offers sufficient opportunities for the Family Nurse Practitioner to educate both parents about paternal postpartum depression. 

The provision of the anticipatory guidance including the risk causal factors and symptoms play a crucial role regarding helping the new fathers to recognize the emerging new feelings after the child has been born and to understand when they should seek help (Howard et al., 2005). Currently, few programs are available to manage the paternal postpartum depression efficiently; therefore, the FNP has a critical role to play to address such gap. Based on the fact that fathering interaction might be a pathway that paternal postpartum depression influences the development of an infant, researchers have highlighted the significance of early postpartum months for father-child relationship‘s development. There is the need to come up with sufficient interventions that are primarily designed to alleviate paternal postpartum depression and enhance interpersonal communication overall quality between the infants and the fathers. Some of the available Family Nurse Practitioner’s opportunities for the efficient patient screening, education and even disease prevention are as follows: verbal discussion, the poster available in the examination room, prenatal examination in addition to the risk factor assessment throughout the birth hospital stay. 

Lack of a sufficient network support and understanding for the new dads is a common issue today. Over the years, paternal postpartum depression postpartum depression is considered a maternal phenomenon, and most research about postpartum mood disorders centres on new mothers, however, fathers can and do experience these issues, and it dramatically affects the family. Paternal depression is often excluded when dealing with growth and development but effects on the child. There has been an increased prevalence of fathers experiencing postpartum depression symptoms. Over the years, the fathers were considered as the providers of support to their partners; however, recently fathers are increasingly involved in parenting an aspect that has further subjected them to postpartum depression. Paternal depression throughout the postnatal period seems to exert significant influence on the subsequent behaviour of the children mainly through the family environment mechanism such as couple conflict and maternal depression. The fathers with postpartum depression throughout the postnatal period have further reported increased parenting distress rates and lower senses of parenting efficacy hence the need to come up with a practical solution to help address paternal depression. Fathers should be encouraged to immediately seek help from well informed and competent practitioners for complete evaluation and consider community resources and support groups may significantly improve their family health and relationships. 

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