Promoting Postpartum Mental Health in Fathers: Recommendations for Nurse Practitioners.

The transition to fatherhood can challenge the mental health of first-time fathers and heighten their risk for postpartum depression (PPD). Paternal PPD not only affects the individual, but relationships with partners and children as well. This scoping review explores paternal PPD, highlighting the factors for and impacts of paternal PPD, the experiences of first-time fathers during the postnatal period, including their knowledge gaps and learning preferences. Drawing on the scoping review findings, recommendations are made for postnatal programs to improve the inclusion of new fathers amid describing how nurse practitioners can promote men's mental health in the postpartum period.

Fatherhood can be a milestone in a man’s life that comes with excitement and challenges; however, little is known about the needs and mental health experiences of new fathers (Thomas, Bonér, & Hildingsson, 2011). In contrast to previous generations, men are expected to be more involved in the various phases of pregnancy, birth, infant care, and child-rearing (Beaupré, Dryburgh, & Wendt, 2014). With these shifts in contemporary fathering roles, it is important to thoughtfully consider how nurse practitioners (NPs) can best promote the health of new fathers. The current scoping review offers a synthesis of the literature pertaining to father’s mental health as a means to making recommendations for postnatal programs and describing how NPs can promote men’s mental health in the postpartum period. Clinically, paternal postpartum depression (PPD) is often under-screened and undetected; but, as NPs have increasing autonomy to practice and prescribe without physician supervision (Carlson, 2017), caring for and treating depression among first-time fathers and their families is an important health condition to understand.

Paternal Postpartum Depression

There is evidence that the transition to fatherhood can cause anxiety and depression, putting men at risk for mental illness, and negatively affecting other family members (Bergström, 2013; Canadian Mental Health Association, 2014). According to a meta-analysis of 43 studies, 10.4% of new fathers experience depression compared to 4.8% of the general male population; however, there is considerable variability in reported prevalence of PPD, location of studies related to prevalence, and timing within the postpartum period (Paulson & Bazemore, 2010). Researchers have reported that paternal PPD occurs in 4% to 25% of new fathers during the first postpartum year; however, because PPD is poorly recognized in men, prevalence may be underreported (Stadtlander, 2015). Further compounding this issue is that many men are reticent to access health-care services; in Canada, it has been estimated that 80% of males refuse to seek medical care until persuaded by their partner (Goldenberg, 2014). In the United States, men are far less likely than women to be in contact with a doctor, and twice as likely to have never visited a doctor (Centers for Disease Control and Prevention, 2015). Financial instability, older age, low education levels, depression in the mother, and relationship issues with spouse and children have also been associated with paternal PPD (Edward, Castle, Mills, Davis, & Casey, 2015). Paternal PPD has been correlated with maternal PPD (Letourneau, Duffett-Leger, Dennis, Stewart, & Tryphonopoulos, 2011; Nishimura, Fujita, Katsuta, Ishihara, & Ohashi, 2015). In the postnatal period, the 12 months following a child’s birth, it is estimated that rates of depression range from 24% to 50% for fathers whose spouses experience maternal PPD (Letourneau et al., 2011). A Canadian pilot study reported that when maternal PPD was present, some fathers also experienced symptoms of depression including “anxiety, sleep disturbances, fatigue, irritability, sadness, changes in appetite, and thoughts of bringing harm to self or baby” (Letourneau et al., 2011, p. 43). Paternal PPD has also been associated with psychological issues that emerge in children in later years (Edward et al., 2015).

During the postnatal period, parents often seek health-related services and programs for their infants. These visits can be opportunistic for health-care professionals, including NPs, to connect with new fathers and assess their health and well-being. In addition, by incorporating NPs into postpartum programs, opportunities for screening, diagnosing, managing, and referring fathers, especially those at risk for serious mental health issues, can occur (Musser, Ahmed, Foli, & Coddington, 2013). To better understand how NPs can promote men’s mental health in the postpartum period, a scoping review focused on paternal postpartum experiences was undertaken. Drawing on the scoping review findings, recommendations are made for postnatal programs to improve the inclusion of new fathers amid describing how NPs can promote men’s mental health in the postpartum period.

Search Strategy

Scoping reviews are appropriate when a field of knowledge is nascent, and a summary of the literature is needed to identify emergent trends and gaps in evidence (Arksey, & O’Malley, 2005). The current scoping review adhered to the framework detailed by Arksey et al. (2005) comprising a set of five clearly defined steps: identifying the research question, identifying relevant studies, selecting the research studies to include, charting the data, and summarizing the results. This framework does not require an assessment of study quality, or inclusion criteria based on quality; rather, the focus is on rapidly summarizing a field of research to inform practice, policy and/or identify future research directions (Arksey et al. 2005). The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE with full text databases were searched using the following keywords in a variety of combinations: father*, transition, postpartum, postnatal, experience, new fathers, support, first-time fathers, depression, men’s health, paternal, and maternal. The searches collectively retrieved 4,562 articles. Titles and abstracts of each article were reviewed for relevancy based on inclusion criteria. The inclusion criteria for articles were empirical studies published from 2011 to 2016 inclusive; English language; and focused on men who were first-time fathers of full-term infants and maintained a relationship with their child’s mother. Review articles were excluded as were studies that focused on preterm infants, newborns requiring hospitalization, father’s experience of the birth, maternal depression, or prenatal paternal depression and adoption.

Eighteen articles met the inclusion criteria and comprised the data for this scoping review. Eight (42%) of the studies were conducted with fathers in the UK, 13 (72%) employed quantitative methods, of which 5 (26%) were longitudinal designs. To analyze and compare the selected articles, a review matrix was developed to extract relevant data from each article (see Table 1). The review matrix included an evaluation of the study design, sample, and results of the selected articles. Data extracted from the 18 articles were analyzed and compared to derive patterns and themes. The results are shared through three themes: (a) factors for and impacts of paternal PPD, (2) experiences of becoming a first-time father, and (3) learning needs and preferences of first-time fathers.

Table 1.

Review Matrix of Selected Articles Regarding Paternal PPD and Fathers’ Experiences.

Author(s)/year	Study design, location, sample	Results
Bergström (2013)	RCTSweden812 fathers	Younger fathers had an increased risk for depressive symptomsLow educational level, low income, poor partner relationship quality, and financial worry increased the risk for depressive symptoms, but these factors could not explain the increased risk among the young
Chin, Daiches, and Hall (2011)	QualitativeUK9 fathers	Fathers searched for their role, position in relation to partner, child, and workFathers felt emotionally and physically detached and sometimes experienced sense of belonging and involvementFathers felt valued, effective, significant in their role; active versus passiveChanging focus of affection in relation to love and attention from partners
Chin, Hall, and Daiches (2011)	MetasynthesisUK, Sweden, Australia96 fathers	Emotional reactions to phases of transition: “detached, surprise, and confusion.”Identifying their role as father: the “approachable provider.”Redefining self and relationship with partner: the “more united tag team.”
Cooklin et al. (2015)	LongitudinalAustralia3,243 fathers	Long and inflexible work hours, night shift, job insecurity, a lack of autonomy, and more children in the household were associated with increased work–family conflict, and this was in turn associated with increased distress.
Cosson and Graham (2012)	QualitativeAustralia27 fathers	Fathers believed themselves to be part of a “parenting team” and that lack of recognition of this fact impacted on their level of engagement with support services
deMontigny, Girard, Lacharité, Dubeau, and Devault (2013)	Descriptive-correlationalCanada205 fathers	Depression in fathers of breastfed infants was associated with the experience or perinatal loss in a previous pregnancy, parenting distress, infant temperament (difficult child), dysfunctional interactions with the child, decreased marital adjustment, and perceived low parenting efficacy
Giallo, Cooklin, Wade, D’Esposito, and Nicolson (2014)	LongitudinalAustralia2,025 fathers	Relationship between fathers’ postnatal distress and children’s outcomes was mediated by parenting hostility (angry and frustrated reactions toward the child such as yelling, and this remained significant after controlling for fathers’ concurrent mental health and mothers’ postnatal mental health
Gutierrez-Galve, Stein, Hanington, Heron, and Ramchandani (2015)	Longitudinal studyEngland13,822 parents and children	Family factors (maternal depression and couple conflict) mediated two-thirds of the overall association between paternal depression and child outcomes at 3.5 yearsSimilar findings were seen when children were 7 years oldFamily factors mediated less than one-quarter of the association between maternal depression and child outcomesNo evidence of moderating effects of either parental education or antisocial traits
Kowlessar, Fox, and Wittkowski (2014)	QualitativeUK10 fathers	Early days of fatherhood, fathers felt helplessness, parented using trial and error, observed and followed mother–baby interactions, worked with their partners and gained confidence and regained control
Letourneauet al. (2011)	Qualitative (pilot study)Canada11 fathers	Fathers experienced depressive symptoms including: anxiety, lack of time and energy, irritability, feeling sad or down, changes in appetite, and thoughts of harm to self or babyCommon barriers to accessing support including not knowing where to look for PPD resources and difficulty reaching out to others
Nishimura et al. (2015)	Cross-sectionalJapan807 couples	Paternal depression was positively associated with partner’s depression and negatively with marital relationship satisfaction
Ramchandani et al. (2011)	Controlled comparisonUK54 fathers with depression and 99 fathers without depression	Fathers in depressed group had less satisfaction with relationship and showed less affection, and higher levels of criticism toward and from partner; key finding fathers’ depression linked to family disharmony and infants with higher levels of distress; emphasized importance of screening for depression in men as well as women
Serhan, Ege, Ayrancı, and Kosgeroglu (2012)	Cross-sectionalWestern Turkey110 couples	EPDS scores significantly higher in mothers who said that their relationship with their husbands were moderate or bad, who felt partly sufficient in baby care, who experienced difficulty in providing baby care, who felt anxious about motherhood, and who did not receive support from anybody for baby careSignificantly higher depression found in unemployed fathers
Sethna, Murray, and Ramchandani (2012)	Individually matched designUK38 fathers	Depression in fathers was associated with more speech focused on the paternal experience and less on the infants’ experienceDepressed fathers’ speech comprised more negative and critical utterances, compared with nondepressed fathers
Sethna, Murray, Netsi, Psychogiou, and Ramchandani (2015)	ObservationalUK192 fathers	Paternal depression was associated with more withdrawn parental behavior in interactions on the floor–mat play setting
Smith, Eryigit-Madzwamuse and Barnes (2013)	LongitudinalUK705 parents	Paternal postnatal depressive symptoms predicted more father-reported child problems at 51 months
Thomas et al. (2011)	Prospective, longitudinalSweden827 fathers	Fathers who were most concerned about their new role were those that were university educated, first-time fathers, and those with financial worriesLack of support from partners after the birth increased fathers’ concern
Tohotoa et al. (2012)	RCT with repeated measuresAustralia680 fathers	At 6 weeks, postnatal fathers in the intervention showed significantly lower anxiety scores. The number of fathers whose anxiety increased at 6 weeks was also fewer than fathers in the control group. Depression scores were similar between groups but most fathers did not register a score for depression

Note. PPD = postpartum depression; RCT = randomized controlled trial; EPDS = Edinburgh Postnatal Depression Scale.

Factors for and Impacts of Paternal Postpartum Depression

Factors for paternal PPD included negative emotions, financial concerns, balancing work–life demands, low education levels, and marital problems. In addition to depression, other mental health issues occurred for some fathers in the postpartum period, including helplessness and anxiety (Chin, Hall, & Daiches, 2011; Kowlessar et al., 2015). Lack of knowledge and lack of postnatal support were factors perceived by first-time fathers in contributing to these negative emotions (Chin, Hall, & Daiches, 2011; Kowlessar, et al., 2015). Fortunately, anxiety levels seemed to decrease for fathers when they became more confident in their infant care skills (Chin, Hall, & Daiches, 2011). Similarly, a randomized controlled trial (RCT) testing an education intervention for fathers reported that men who received the antenatal and postnatal gender-specific intervention had significantly lower anxiety scores at 6 weeks post baseline compared with the control group of fathers (Tohotoa et al., 2012).

Significantly, financial instability was associated with depression in new fathers (Bergström, 2013; Serhan et al., 2013). Serhan et al. (2013) reported that unemployed fathers scored higher on the Edinburgh Postnatal Depression Scale (EPDS) (a screening tool for PPD) than those who had jobs or were self-employed (p < .05) (Serhan et al., 2013). Bergström (2013) similarly reported that men’s depressive symptoms were associated with low household income and apprehension about unemployment and economic uncertainty. A significant correlation between paternal PPD and anxiety about the economy was also reported in a Japan-based study, wherein paternal PPD rates were 13.6% at 4 months postpartum, increasing to 19.4% at 12 months postpartum (Nishimura et al., 2015).

Fathers often assumed increased responsibility to ensure adequate income for their family in the postpartum period. The pressures to maintain or increase income levels and maintain job performance amid the new demands of infant caregiving, sleep deprivation, and changes to the couple’s relationship posed significant challenges (Cooklin et al., 2015). In balancing fatherhood and employment, fathers who worked long hours, shift work, or had inflexible employment situations reported higher work–family conflict and more distress (Cooklin et al., 2015). In sum, financial pressures were multifactorial, comprising work and family responsibilities as well as unemployment and/or job insecurity, which heightened fathers’ stress and anxiety levels and risk for PPD.

Low levels of education were also associated with paternal PPD (Bergström, 2013; Sethna et al., 2012). Fathers with low levels of education, who also experienced depression, were more likely to exert negative effect on their children. Compared to fathers with degree-level education, fathers without those credentials “used a greater proportion of infant-focused negative comments” (Sethna et al., 2012, p. 2366). It is important to note that low levels of education and financial strain, as independent risk factors, have been associated with major depressive episodes (MDE) in the general population (Wang, Schmitz, & Dewa, 2010). It is possible that in the postpartum period, the two factors may be associated.

Marital problems, including decreased quality of the couple’s relationship were significantly associated with paternal PPD (Bergström, 2013; deMontigny et al., 2013; Gutierrez-Galve et al., 2015; Nishimura et al., 2015). The directionality of this association was unclear; a correlational study with 54 fathers diagnosed with depression and 99 fathers without depression reported that the depressed group had less satisfaction with their relationship, and showed less affection with higher levels of criticism toward and from their partners (Ramchandani et al., 2011).

Paternal PPD was also associated with fathers’ perceptions of the relationship with their child and verbal and physical communication with their child (Giallo et al., 2014; Gutierrez-Galve et al., 2015; Sethna et al., 2012; Sethna et al., 2015). In a study with 205 fathers, deMontigny et al. (2013) stated that the perception of a poor relationship with their child was a significant factor associated with depression. Fathers who had depression exhibited less verbal communication with their infants than nondepressed fathers (Sethna et al., 2012) and were more likely to have distressed infants (Ramchandani et al., 2011). When communicating with infants, phrases spoken by depressed fathers were self-focused, and contained increased negativity and infant-directed critical comments (Sethna et al., 2012). An observational study reported that fathers who had depression were more withdrawn, and used less verbal and physical contact with their infants (Sethna et al., 2015).

Paternal PPD-associated marital issues can also mediate children’s behavioral issues (Giallo et al., 2014; Gutierrez-Galve et al., 2015; Sethna et al., 2012; Smith, Eryigit-Madzwamuse, & Barnes, 2013). A longitudinal study with 705 parents revealed that the symptoms of mental illness in fathers at 3 months postpartum were associated with behavioral problems of children at 4 years of age (Smith et al., 2013). The authors concluded that fathers’ mental health in the postpartum and children’s future behavioral problems were mediated by marital conflicts that had occurred at 3 months postpartum (Smith et al., 2013). The authors also reported that PPD symptoms and mental health issues in fathers measured at 36 months postpartum were a significant predictor of child socio-emotional issues (as reported by the parents) at age 5 years, even when other variables were controlled (Smith et al., 2013). Similarly, Gutierrez-Galve et al. (2015) reported that couple conflict indirectly linked paternal PPD to mental health problems in the child at 3.5 and 7 years of age. A longitudinal study with more than 2,000 fathers reported that fathers with high distress in the postnatal period were significantly more likely to parent with high levels of hostility, a factor in the emotional and behavioral challenges seen in their children at 4 to 5 years of age (Giallo et al., 2014).

Experiences of Becoming a Father

For first-time fathers, the postpartum period often entails the experience of new emotions, role development, work and knowledge barriers to infant involvement, and a lack of father-specific support and resources. Fathers have reported disconnection in their intimate relationship and difficulty finding private time with their spouse (Chin, Daiches, & Hall, 2011). Despite the changes in intimacy and decreased spontaneity, positive changes can also occur (Chin, Hall, & Daiches, 2011). After the arrival of the baby, a majority of men discovered that the relationship with their partner had unified, increasing in strength and depth, and created wholeness and cohesiveness in their lives (Chin, Hall, & Daiches, 2011). The obligations of fatherhood can motivate men toward personal growth, the desire for greater self-care, and less risky behaviors (Chin, Hall, & Daiches, 2011).

Taking on new father roles could also surface doubts and challenges for men, in which they repositioned themselves in relation to their partner, child, and work (Chin, Daiches, & Hall, 2011). First-time fathers described themselves as feeling like a bystander to the mother–infant bond, more detached than they had envisioned (Chin, Daiches, & Hall, 2011). For men who may have experienced the antenatal period as difficult, during the postpartum period fathers started feeling more involved and settled into a supportive role, as they recognized the baby’s mother was a proficient, capable caregiver (Chin, Daiches, & Hall, 2011). In contrast to mothers, men tended to view themselves as parents who engaged with their child mainly during play and physical activity (Chin, Hall, & Daiches, 2011).

Several articles described how competing emotional needs to be an involved father conflicted with breadwinner obligations (Chin, Daiches, & Hall, 2011; Chin, Hall, & Daiches, 2011). Upon returning to work after a short paternity leave, fathers felt conflicted by how the long work hours required to maintain income resulted in less time spent with their baby (Kowlessar et al., 2015). Many men felt torn between their partner’s wishes, their employer’s needs, and their family’s economic situation (Kowlessar et al., 2015). The pressures to be a successful breadwinner prevented some fathers from being with their child, accompanying them to parent–child events, and medical appointments (Chin, Daiches, & Hall, 2011). These absences could create emotional detachment from their family, unhappiness, and feelings of exclusion (Chin, Daiches, & Hall, 2011).

Many men reported struggling with their new roles due to a lack of knowledge, expressing disappointment with the lack of information or programs targeted specifically for fathers; as a result, men often sought information and support through their wives and coworkers (Chin, Daiches, & Hall, 2011; Kowlessar et al., 2015; Thomas et al., 2011). Unfortunately, many first-time fathers perceived and conceded that their needs were unimportant (Kowlessar et al., 2015), which hindered seeking out and/or requesting information. Indeed, many fathers reported poor social support systems in the postpartum period (Kowlessar et al., 2015; Thomas et al., 2011). After returning to work, first-time fathers indicated that coworkers, who were parents, provided support, aiding men in navigating the mental and emotional challenges involved in being a working father (Chin, Daiches, & Hall, 2011; Kowlessar et al., 2015; Thomas et al., 2011).

Learning Needs and Preferences of First-Time Fathers

Fathers have expressed that it would be beneficial to know more about infant care, about their role as a father, and potential relationship changes or strains that might be expected with their partners (Kowlessar et al., 2015). The desire to, but uncertainty about participating in the care of the infant was also widely reported (Chin, Hall, & Daiches, 2011; Kowlessar et al., 2015). Fathers indicated that information through digital media, Internet, father-targeted sessions, and learning from experienced parents would be most beneficial (Chin, Hall, & Daiches, 2011). Informational DVDs and other digital media about fathering in the postnatal period allows first-time fathers flexibility and convenience for learning at their own time, place, and with others.

Research has confirmed men’s frustrations about the absence of father-focused sessions pertinent to postpartum issues and skills (Kowlessar et al., 2015; Thomas et al., 2011). Even though fathers attended programs and appointments in the antenatal and/or postnatal periods, they reported being excluded, without having their learning needs met (Kowlessar et al., 2015). Fathers were frustrated by health-care professionals’ presumptions that they were inefficient caregivers relegated to a secondary caregiver status (Cosson & Graham, 2012). It is important to note that the learning suggestions made by first-time fathers all favored elements of active participation on their part.

Discussion and Conclusion

Based on the findings from this scoping review, the following recommendations are offered for postnatal programs targeting first-time fathers, with a focus on how NPs might lobby and facilitate those services. Firstly, postnatal programs could offer one session a month on an evening or weekend to accommodate many working fathers. Ideally, these sessions would be father-and-baby invite only to enhance the relationship between father and child and to create an environment where fathers can meet to develop mutually supportive peer relationships that can grow beyond the program. The Sure Start Children’s Centres (SSCC) in Hinton, England has delivered a successful program for fathers of disadvantaged children under the age of 5 years (Coleman, Sharp, & Handscomb, 2016). In an evaluation of the program, parents perceived father–child-only sessions as beneficial for both the father and child (Potter & Carpenter, 2010). Fathers reported that one-on-one time spent with their child helped in building stronger attachments (Potter & Carpenter, 2010). Socialization and peer support were also perceived by parents as important benefits in an all-father session which helped to reduce social isolation experienced by new fathers, and allowed for open discussions between men (Potter & Carpenter, 2010).

Secondly, in an informal setting, information sessions or programming components should focus on the learning gaps identified in the literature and by fathers themselves. Because men often prefer to learn in less formal, practical, group formats (Golding, 2005), addressing gender-specific learning preferences can foster effective learning. Activities can include infant care, the fathering role and anticipatory relationship changes, challenges, and supports. Other topics of interest to men can be offered: first-aid treatment, infant massage, infant/toddler activities and play, stress-reducing strategies, date-night ideas, and three ingredient family meals. Potter and Carpenter (2008) discovered that consulting with fathers on the activities they wished to engage in was an appealing factor and motivation to participate. Father-focused sessions such as this could also promote self-care and healthy lifestyle habits for fathers. Oliffe, Bottorff, and Sarbit (2012) indicated that supporting a group of men in their fathering roles allowed for open dialogue about fatherhood, a context in which men also discussed healthy changes such as smoking cessation experiences, and exercise. The SSCC program, previously mentioned, offered a successful martial arts class for fathers and incorporated a range of strategies to also teach relaxation and anger management rather than focusing only on competition in sports (Golding, 2005; Potter & Carpenter, 2008).

Thirdly, peer and online resources should be promoted for first-time fathers. Opportunities for fathers to connect with fathers of older babies and toddlers should be created to provide peer support, especially for those lacking male connections. Online resources, such as the Pacific Post Partum Support Society (PPPSS) (developed in Vancouver, Canada), provides resources, articles, and personal accounts for new fathers regarding PPD and anxiety. The resource also informs men about the symptoms of depression and anxiety, and provides the EPDS for self-assessment, which can help verify experiences and encourage men to seek medical attention.

Optimizing the Role of Nurse Practitioners

Based on current evidence, it is clear that fathers require tailored, gender-specific guidance as they transition into fatherhood. By recognizing fatherhood as an opportunity to promote men’s health, NPs can be the connection for fathers to primary health care and advocate for improved, father-focused postnatal programs. The NP role is well suited for assessing, screening, and managing PDD in fathers (Musser et al., 2013). In regards to screening tools, the Patient Health Questionnaire (PHQ-9) has been critiqued as inaccurate for detecting depression in men (Gagnon & Oliffe, 2015). On the other hand, the EPDS has been assessed as a highly validated tool to screen for PPD in both mothers and fathers (Bergström, 2013; deMontigny et al., 2013; Gutierrez-Galve et al., 2015). More recently, the Male Depression Risk Scale (MDRS) has accrued interest as a tool that is sensitive to depression symptoms such as anger, substance misuse, and risk-taking behaviors (Rice, Fallon, Aucote, Möller-Leimkühler, 2013). Being a risk scale, more studies are required to test its accuracy in predicting depression (Rice et al., 2013); however, it is important for NPs to be aware that male-specific depression screening tools are emerging. Gagnon and Oliffe (2015) advised that the use of open-ended, loop, and probe questions is also a good clinical communication skill to identify depressive symptoms among men.

Additional research is required to further understand the paternal postpartum experiences and needs of first-time fathers. By creating opportunities for men to access health-care services through an NP, it may be possible to reduce gender-related health inequities and better promote men’s health, and by extension, the health of their family.