It is understood that around 1 in 10 men experience postnatal depression (Paulson and Bazemore, 2010). Fathers’ experiences of perinatal mental health difficulties have been associated with maternal mental ill health (Paulson et al., 2016), and with adverse offspring outcomes such as conduct problems and psychiatric illness (Gentile and Fusco, 2017).
Considering this, men’s perinatal mental health should be a priority for public and family health initiatives and for perinatal mental health services, which have been prioritised for investment and expansion under the UK NHS Long-Term Plan and Mental Health Implementation Plan (The NHS Long Term Plan, 2019; 2019a). This is especially relevant for early detection of the most at-risk men, and to improve outcomes and promote overall wellbeing in families during a crucial point of transition and child development (Bruno et al., 2020).
However, much existing research into men’s perinatal mental health is cross-sectional, and based on retrospective reporting (Chhabra, McDermott & Li, 2020; Wee et al., 2011). The limited longitudinal research that is available has identified significant predictors of paternal postnatal depression such as a past history of severe depressive symptoms and high prenatal scores on measures of depression and anxiety symptoms (Ramchandani et al., 2008).
There is a lack of prospective studies which identify preconception risk factors for suicidal ideation, as well as depressive symptoms in new fathers. Evidence like this, especially that which examines broad psychosocial factors that can be detected early, is necessary to inform approaches to preconception care and family health initiatives.
Giallo and colleagues (2023) used prospective data from an Australian national longitudinal study examining men’s health, the ‘The Ten to Men Study’, with the aim of determining the extent to which new fathers report depressive symptoms and suicidal ideation/behaviour in the first year postpartum, and the preconception risk factors associated with these symptoms.
1 in 10 men experience postnatal depression, yet there is not enough prospective research to establish the precipitating risk factors.
Methods
‘The Ten to Men Study’, is an Australian population-based prospective cohort study examining male health. The overall study assessed males aged 10-55 living permanently across Australia, firstly between 2013 and 2014 (‘wave 1’), and at follow-up between 2015 and 2016 (‘wave 2’). See Currier et al. (2016) and Spittal et al. (2016).
The current study used data from 205 men in the adult cohort who had indicated that they became a father in the 12 months prior to wave 2 data collection.
The fieldworkers who conducted recruitment and data collection in the study completed survey measures of demographic information, including age, Aboriginal origin, address, country of birth, first language, education, employment, and relationship status.
The other main concepts measured were: depression, suicidality, stressful life events including financial difficulties, experiences of partner violence, and social support. Alcohol and drug use (including cigarette and cannabis smoking), and physical health needs, were also measured by questionnaires.
The study used bivariate and multivariate linear regression analyses to identify preconception factors associated with postnatal depressive symptoms (PHQ-9), from the mental and physical health, lifestyle, and demographic factors assessed.
Alongside age, first spoken language, and education, metropolitan or rural/remote address status was also included as an indicator of economic status, based on evidence of higher suicidality in males in rural Australia (Fitzpatrick et al., 2021).
Results
The majority of men were born in Australia (78.9%), were English speaking (89.8%), and had at least high school level education (68.8%). At wave 1 data collection, most were in paid employment (89.1%) and had a partner (79.3%).
1 in 4 of the fathers assessed at waves 1 and 2 reported mild postnatal depressive symptoms. Just over 8% reported symptoms that were moderate or severe. Depressive symptoms were not found to significantly worsen from preconception to postnatal data collection (7.8% and 8.3% respectively).
5% of men reported thoughts of suicide, made a plan for suicide, and/or attempted suicide in the 12 months prior to wave 2 data collection.
Preconception depressive symptoms were the only significant predictor of future depressive symptoms after birth.
Financial difficulties, lifetime suicidal ideation, and violent partner relationships, were also found as other factors for postnatal depression using the bivariate analyses, but these did not reach statistical significance in the multivariate model.
1 in 4 fathers reported mild postnatal depressive symptoms following the birth of their baby and 5% reported suicidal thoughts, plans or attempts.
Conclusions
This study supports the few existing prospective studies of risk factors for men’s postnatal mental health, by indicating that for some first-time fathers, the first year postnatally is associated with moderate or severe depressive symptoms and suicidality. As paternal perinatal depression is not well researched or officially recognised as a disorder in the DSM-5 (Bruno et al., 2020), this research contributes to growing literature focusing on paternal perinatal mental health, which will help it to be better defined, detected, and managed.
Experiences of depressive symptoms prior to the conception of their child, measurable by a validated screening measure, are a significant predictor of these later mental health difficulties. The authors thereby conclude that this finding:
…underscores the importance of preconception and perinatal mental health care for men as they make the transition to fatherhood [which] they are not routinely offered […] in universal settings.
These findings emphasise the need for preconception and perinatal mental health care for men as they become fathers; highlighting that such care is not routinely provided in universal settings.
Strengths and limitations
This study contributes to a specific gap in the literature addressing fathers’ perinatal mental health, which is receiving increased research and clinical attention. A strength of this research is the methodological choice to focus “on risk factors that general practitioners/physicians and other health professionals are well placed to identify among men when providing pre-conception or prenatal care”, including lifestyle and psychosocial factors. This conveys high ecological validity for real world applications.
This, and other aspects of the study’s methodology including the examination of remoteness of participants’ addresses based on existing knowledge of health disparities, and the use of a geographically representative cohort, demonstrate the authors have made considerations for the external validity and application of their findings.
Additionally, the study employed a validated and widely used self-report measure of depression (PHQ-9), which has also been applied to perinatal depression in mothers (Sidebottom et al., 2012; Wang et al., 2021) and fathers (Berg et al., 2022). In these studies, the PHQ-9 has been a resource-efficient and feasible measure to implement into routine prenatal care, making it appropriate for a large population-based cohort such as the ‘Ten to Men Study’. However Giallo and colleagues (2023) recognise that a diagnostic interview of participants’ mental health would have provided a stronger and more comprehensive understanding of the nature and prevalence of specific mental health symptoms in the sample.
The authors acknowledge the low response rate of 35% of all eligible males who were contacted to enrol in the study. In particular, the authors note that “those who speak English as a second language…may have chosen not to participate in the study”. This is especially important considering structural barriers faced by people who do not speak the language of their resettlement country (Byrow et al., 2019; Ahrne et al., 2019) when seeking support, and recently-settled immigrant fathers’ experiences of having lost their extended families after migrating (Forbes et al., 2021). The outcomes of this study alone cannot be generalised to these populations who may present with unique preconception risk factors, and further research targeting non-English speaking fathers should be considered.
Finally, selective attrition of participants with higher depressive symptoms and cigarette, alcohol, and drug use, was noted in wave 2. This bias may have made the study’s estimates of the prevalence of depression and suicidality more conservative, and may mean that the study did not pick up the specific risk factors associated with depression in these participants, who were missing from analyses.
This prospective study has strong external validity, though may represent only a small proportion of first-time fathers.
Implications for practice and research
As a result of the small available sample, the number of fathers reporting suicidal ideation was too low to conduct regression analyses of risk factors for suicidality. As suicidal intention and planning is a specific risk concern, it is especially important that we understand the relevant risk factors. This may have been enhanced by including qualitative interviews with participants who disclosed suicidal ideation, to examine and identify some relevant self-reported risk factors for suicidality, which could inform future research. This should be a focus of future research attention which seeks to understand the factors relevant to fathers’ postnatal suicidality.
This study and the related body of research (see Darwin et al., 2017) advocates for a move toward universal screening and support for male partners’ and fathers’ mental health in the perinatal period. The authors describe a need for “research and advocacy efforts” to increase healthcare practitioners’ awareness and confidence in engaging men in discussions around paternal perinatal mental illness, furthering the evidence base for effective and feasible interventions for fathers and male partners, and universally implementing perinatal physical and mental health care for men (Giallo et al., 2023).
As fathers have been found to “question the legitimacy of their experiences” of psychological distress in the perinatal period, and often worry that voicing their concerns may “detract from their partner’s needs”, Darwin et al. (2017) acknowledge the need for future research, which can build on the important and measurable risk factors identified by Giallo and colleagues’ (2023), to inform resources that are tailored fathers’ roles as ‘supporter’ and ‘protector’, “in the context of achievable models of service delivery” (Darwin et al., 2017).
One useful target for future research to achieve this aim of health promotion, prevention, and early intervention in men’s mental health could be to incorporate these known risk factors which are present preconception, with existing efforts to identify and implement low-cost and non-stigmatising screening measures of mens’ mental health (e.g. MacDonald et al., 2021) at the transition to fatherhood.
The findings suggest benefit in screening fathers for depression preconception in order to direct appropriate resources to fathers most at risk of developing postnatal suicidality and/or depression.
Statements of interest
None to declare.
Links
Primary paper
Giallo, R., Wynter, K., McMahon, G., Seymour, M., Fogarty, A., Cooklin, A., … & Macdonald, J. A. (2023). Preconception factors associated with postnatal mental health and suicidality among first-time fathers: results from an Australian Longitudinal Study of Men’s Health. Social psychiatry and psychiatric epidemiology, 1-8.
Other references
Australian Bureau of Statistics. (2003). Household expenditure survey and survey of income and housing costs. Australian Bureau of Statistics, 6530.0.
Australian Bureau of Statistics. (2007). National Health Survey 2007-08: module E-healthy lifestyles. Australian Bureau of Statistics, 4364.0.
Berg, R. C., Solberg, B. L., Glavin, K., & Olsvold, N. (2022). Instruments to identify symptoms of paternal depression during pregnancy and the first postpartum year: a systematic scoping review. American Journal of Men’s Health, 16(5), 15579883221114984.
Bruno, A., Celebre, L., Mento, C., Rizzo, A., Silvestri, M. C., De Stefano, R., … & Muscatello, M. R. A. (2020). When fathers begin to falter: a comprehensive review on paternal perinatal depression. International journal of environmental research and public health, 17(4), 1139.
Chhabra, J., McDermott, B., & Li, W. (2020). Risk factors for paternal perinatal depression and anxiety: A systematic review and meta-analysis. Psychology of Men & Masculinities, 21(4), 593.
Currier, D., Pirkis, J., Carlin, J., Degenhardt, L., Dharmage, S. C., Giles-Corti, B., … & English, D. R. (2016). The Australian longitudinal study on male health-methods. BMC Public Health, 16(3), 5-13.
Darwin, Z., Galdas, P., Hinchliff, S., Littlewood, E., McMillan, D., McGowan, L., & Gilbody, S. (2017). Fathers’ views and experiences of their own mental health during pregnancy and the first postnatal year: a qualitative interview study of men participating in the UK Born and Bred in Yorkshire (BaBY) cohort. BMC pregnancy and childbirth, 17(1), 1-15.
Donovan, C., Hester, M., Holmes, J., & McCarry, M. (2006). Comparing Domestic Abuse in Same Sex and Heterosexual Relationships. University of Bristol.
Eaton, D. K., Kann, L., Kinchen, S., Shanklin, S., Flint, K. H., Hawkins, J., Harris, W. A., Lowry, R., McManus, T., Chyen, D., Whittle, L., Lim, C., Wechsler, H., & Centers for Disease Control and Prevention (CDC) (2012). Youth risk behavior surveillance – United States, 2011. Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C. : 2002), 61(4), 1–162.
Fitzpatrick, S. J., Handley, T., Powell, N., Read, D., Inder, K. J., Perkins, D., & Brew, B. K. (2021). Suicide in rural Australia: A retrospective study of mental health problems, health-seeking and service utilisation. PLoS one, 16(7), e0245271.
Forbes, F., Wynter, K., Zeleke, B. M., & Fisher, J. (2021). Fathers’ involvement in perinatal healthcare in Australia: experiences and reflections of Ethiopian-Australian men and women. BMC Health Services Research, 21, 1-13.
Gentile, S., & Fusco, M. L. (2017). Untreated perinatal paternal depression: Effects on offspring. Psychiatry Research, 252, 325-332.
Gray, M., & Sanson, A. (2005). Growing up in Australia: the longitudinal study of Australian children. Family Matters, (72), 4-9.
Holmes, T. H., & Rahe, R. H. (1967). The social readjustment rating scale. Journal of psychosomatic research.
Macdonald, J. A., Graeme, L. G., Wynter, K., Cooke, D., Hutchinson, D., Kendall, G., … & Youssef, G. J. (2021). How are you sleeping? Starting the conversation with fathers about their mental health in the early parenting years. Journal of Affective Disorders, 281, 727-737.
Pachana, N. A., Brilleman, S. L., & Dobson, A. J. (2011). Reporting of life events over time: methodological issues in a longitudinal sample of women. Psychological assessment, 23(1), 277.
Paulson, J. F., & Bazemore, S. D. (2010). Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. JAMA, 303(19), 1961-1969.
Paulson, J. F., Bazemore, S. D., Goodman, J. H., & Leiferman, J. A. (2016). The course and interrelationship of maternal and paternal perinatal depression. Archives of women’s mental health, 19, 655-663.
Ramchandani, P. G., Stein, A., O’Connor, T. G., Heron, J. O. N., Murray, L., & Evans, J. (2008). Depression in men in the postnatal period and later child psychopathology: a population cohort study. Journal of the American Academy of Child & Adolescent Psychiatry, 47(4), 390-398.
Sidebottom, A. C., Harrison, P. A., Godecker, A., & Kim, H. (2012). Validation of the Patient Health Questionnaire (PHQ)-9 for prenatal depression screening. Archives of women’s mental health, 15, 367-374.
Spittal, M. J., Carlin, J. B., Currier, D., Downes, M., English, D. R., Gordon, I., … & Gurrin, L. (2016). The Australian Longitudinal Study on Male Health sampling design and survey weighting: Implications for analysis and interpretation of clustered data. BMC Public Health, 16, 15-22.
Spitzer, R. L., Kroenke, K., Williams, J. B., Patient Health Questionnaire Primary Care Study Group, & Patient Health Questionnaire Primary Care Study Group. (1999). Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA, 282(18), 1737-1744.
Wang, L., Kroenke, K., Stump, T. E., & Monahan, P. O. (2021). Screening for perinatal depression with the Patient Health Questionnaire depression scale (PHQ-9): a systematic review and meta-analysis. General hospital psychiatry, 68, 74-82.
Wee, K. Y., Skouteris, H., Pier, C., Richardson, B., & Milgrom, J. (2011). Correlates of ante-and postnatal depression in fathers: a systematic review. Journal of affective disorders, 130(3), 358-377.
The NHS Long Term Plan, 2019 The NHS Long Term Plan. 2019; Available from: www.longtermplan.nhs.uk.
NHS England. (2019a). NHS Mental Health Implementation Plan 2019/20 – 2023/24 (p. 57). https://www.longtermplan.nhs.uk/publication/nhs-mental-health-implementation-plan2019-20-2023-24
