Dads get sad, too

This is difficult to write: the day my son was born, I didn't feel the elation, the overwhelming joy, I'd been expecting. Something was missing – a sense of connection to my newborn son maybe, but something more than that, too. I'm not sure I instantly loved him the way my wife did, the way I'd been expecting to love him myself.

As the days passed, my estrangement grew. I felt anxious at the thought of having to spend time with my son, to hold him and be with him. Every time he cried in my arms, I felt as though he were saying he hated me, as though he were rejecting me. I began to feel isolated and alone, and in response, I withdrew – both from my son and wife. There were days when I avoided them entirely, shut myself off completely, and ended up hating myself when I did. I felt useless and unworthy to be a part of the family, unfit to be a father. I struggled to find joy in anything I did. Lethargy set in. I cried a lot. Some days I stayed in bed and other days I hardly slept. I often overworked to the point of burning out. I simply couldn't cope, and yet I never thought of asking anyone for help.

Postnatal Depression

Postnatal depression is well researched in new mothers. Distinct from the 'baby blues' – typically characterised by mood swings, anxiety, irritability, and insomnia in the days following birth – postnatal depression is a non-psychotic depressive disorder that occurs after the birth of a child (O'Hara & Wisner, 2014), sometimes up to a year after delivery though it is most commonly diagnosed within the first three months post-birth (Stuart-Parrigon & Stuart, 2014). Prevalence estimates vary because studies often use different assessment criteria and postnatal timeframes, but meta-analyses suggest an overall prevalence of maternal postnatal depression of between 6 and 13 per cent (Gaynes et al., 2005), with substantially higher estimates of up to about 20 per cent in low- and middle-income countries (Fisher et al., 2012). In short, we know that depression is relatively common in women after delivery.

Researchers also know a good deal about the impact of maternal depression on mother and child outcomes (Lee & Chung, 2007). For example, postnatal depression in new mothers is associated with poorer mother-child attachment in both the short- and long-term (Figueoredo et al., 2009) and shorter breastfeeding duration (Henderson et al., 2003). It is also associated with child development outcomes, including cognitive, language, and behavioural problems (Netsi et al., 2018). Maternal depression also carries a heavy long-term economic cost to society: in the UK, the average cost of one case of maternal depression is around £74,000, with the bulk of the costs relating to adverse impacts on the child (Bauer et al., 2014). The good news is that there is long-standing guidance from national bodies in the UK about what services are needed for mothers affected by depression, how services should be organised, and what they should provide.

Conversely, paternal postnatal depression has not received the same level of attention from researchers and practitioners. One reason for this is that postnatal depression was historically associated with sex-specific hormonal and biological changes associated with giving birth, which in turn meant that new fathers were thought to be less susceptible, perhaps even immune, to depression after the birth of a child. Additionally, stressors that frequently contribute to postnatal depression – including delivery complications, unsuccessful breastfeeding, sudden changes in normal daily activities, lack of sleep, and changes in financial security and familial relationships – were thought to only or disproportionately affect mothers. Perhaps unsurprisingly, until relatively recently, paternal postnatal depression simply did not figure strongly in scholarly research, let alone practitioner guidance.

Fortunately, that has begun to change. There is now much wider recognition that the psychosocial changes that affect mothers after birth can also have a detrimental effect of the mental health of new fathers (Philpott, 2016). In fact, recent studies have reported prevalence estimates of between 8-11 per cent for paternal postnatal depression (Glasser & Lerner-Geva, 2018; Paulson & Bazemore, 2010). Many factors have been identified as contributing to paternal postnatal depression, of which the most common is maternal postnatal depression (Edwards et al., 2014; Zhang et al., 2016): fathers whose partners had postnatal depression were estimated to have a 2.5 times higher risk of depression six weeks after the birth of a child (Matthey et al., 2000). In addition, a previous history of mental health disorders, particularly depression, poses a greater risk for developing paternal postnatal depression (Wee et al., 2011), most likely because of a combination of predisposing genetic factors and the postnatal period acting a stressful life event that triggers the recurrence of depressive symptoms (Philpott & Corcoran, 2018).

Other key factors contributing to paternal postnatal depression include discrepancies between the expectation and realities of childbirth and the postnatal period (Edhborg et al., 2015). In particular, fathers who experience greater difficulties with childcare than they initially expected show greater symptoms of postnatal depression (Gross & Marcussen, 2017). This is perhaps unsurprising given that many new fathers say they do not receive adequate information about appropriate parenting skills and techniques, particularly from family-centred services and their own fathers (Barclay & Lupton, 1999). Likewise, antenatal care is often directed at mothers and lack of information and preparation for pregnancy and childcare are important risk factors for postnatal depression in first-time fathers (Boyce et al., 2007). Difficulties managing childcare responsibilities with a return to work, feelings of isolation (and even jealousy toward their babies) as family attention is diverted to the child, and difficulties with the marital relationship can all also contribute to paternal postnatal depression (Gawlik et al., 2013; Goodman, 2005; Nishimura et al., 2015).

Some of these factors are specific to fathers, particularly the relatively speedier return to work among fathers compared to mothers and societal expectations that fathers both provide financial support for the family while playing an active role in childcare and providing emotional support to their spouses (Darwin et al., 2017; Edhborg et al., 2015; Halle et al., 2008). Self-blame and feelings of failure for the loss of intimacy and sex with partners can also add to fathers' feelings of distress (Morse et al., 2000). There is also some evidence that paternal postnatal depression is related to hormonal changes, particularly decreases in testosterone, prolactin, and oestrogen, in men during the partners' pregnancy and the postpartum period (Sundström Poromaa et al., 2016). Finally, fathers also report more difficulties developing emotional bonds with their children compared to mothers, which may increase feelings of helplessness (Anderson, 1996) and contribute to feeling like a bystander to the mother-infant bond (Chin et al., 2011).

There is also now much wider recognition that paternal postnatal depression can have detrimental impacts not just on fathers themselves – most notably higher suicide risk (Quevedo et al., 2011) – but also on father-child bonding. For example, paternal postnatal depression is associated with poorer father-infant attachment (Ip et al., 2018) and with lower willingness to participate in child-rearing and lower engagement in enrichment activities with the child (Paulson et al., 2006). Depressed fathers are also much more likely to use physical discipline with their children in the first year after birth compared to non-depressed fathers (Davis et al., 2011) and to communicate with their infants in ways that are more self-focused and critical (Sethna et al., 2012). Paternal postnatal depression can also have a negative impact on child development outcomes. For instance, there is now fairly conclusive evidence that children of depressed fathers are substantially more likely to develop behavioural and emotional difficulties, including conduct disorders and hyperactivity (Ramchandani et al., 2013; Sweeney & MacBeth, 2016).

Where is the help for fathers?

Despite these advances in knowledge, new fathers experiencing depression remain less visible than depressed mothers, both within healthcare and societally. One important reason for this is due to gendered constructions of masculinity that emphasise male toughness, stoicism, and self-reliance (Courtenay, 2000; Connell & Messerschmidt, 2005). In simple terms, men experiencing or vocalising symptoms of depression are perceived as transgressing normative expectations and expressions of mainstream masculinity (Krumm et al., 2017). This has a dual impact on men's mental health. First, for men themselves, particularly those who strive for mainstream masculine ideals, asking for help can be incredibly difficult precisely because it is transgressive. Instead, men are much more likely than women to deal with symptoms of depression through self-help – drinking, aggression, and withdrawal are all common responses to symptoms of depression.

It would be easy to dismiss the impact of masculinities on help-seeking behaviour in men. I am a case in point. I have written about the impact of masculinities on men's mental health in The Psychologist (Swami et al., 2008). I have conducted research that links masculinities to poor symptom recognition of depression in men (Swami, 2012). And yet, as I began to experience symptoms of depression following the birth of my son, I found it near impossible to ask for help. A part of this stemmed from a difficulty admitting that I might be depressed, particularly at a period when cultural and family expectations suggested that I should be happy. But there was a great deal of shame, too – shame at my frailty, my uselessness as a father, my inability to 'man up' and face the challenges of caring for my son. To be depressed after the birth of my son felt selfish and I felt shame at the burden I placed on my wife whenever I struggled to function normally, whenever I withdrew. And that shame was debilitating: if I struggled to ask my wife for help, what chance was there of asking for help from practitioners who were strangers to me?

But hegemonically masculine ideals can also mean that practitioners are less likely to recognise symptoms of depression in new fathers or provide opportunities to raise concerns about men's mental health (Hammarlund et al., 2015). I recall trips to see health visitors and midwives, who routinely asked my wife about her mental health after the birth of our son. I was never asked the same questions. I don't mean to blame individual practitioners, but the invisibility of my mental health concerns only forced me further into a false stoicism. This is a common experience: new fathers often describe feeling overlooked when in contact with family-centred services following the birth of a child (Darwin et al., 2017; Fägerskiöld, 2006). In the UK, for example, the tradition and culture of health visiting is heavily focused on mothers and children, and there is a reluctance on the part of some health visitors to address paternal postnatal depression. In part, this is because of a lack of work time, relevant training, and clear guidelines (Oldfield & Carr, 2017), but it also stems from a perception that men are not or cannot be at-risk for depression after the birth of a child (Whitelock, 2016).

Societal norms and attitudes can also act as a barrier to men's help-seeking behaviours. For example, studies suggest that, when members of the public are presented with vignettes of mothers, the ability to correctly label cases of postnatal depression is relatively high, at about 75-90 per cent (Swami et al., 2018; Thornsteinsson et al., 2014). But when identical vignettes of mothers and fathers are presented, members of the public are much less likely to correctly identify postnatal depression in fathers (at about 45 per cent). Instead, fathers showing symptoms of postnatal depression were more likely to be described as "stressed" or "exhausted" rather than depressed (Swami et al., 2018). In other words, lay individuals may be less likely to see the difficulties faced by depressed fathers as issues of mental ill-health and more likely to emphasise factors that are common to most new parents, such as a lack of sleep. This gender binary might mean that fathers delay help-seeking, believing their symptoms to be manageable or because of a fear of being stigmatised for asking for help (Mickelson et al., 2017).

And to the extent that practitioners internalise these negative attitudes, it likely means that men are not given the space and time to air their mental health concerns. In fact, there is very little clinical guidance for assessing and supporting at-risk fathers in the UK. For example, the National Institute for Health Care Excellence (NICE) continues to describe postnatal depression as primarily maternal and highlights the importance of supporting the partner of a depressed mother, but provides no guidance on how to identify paternal postnatal depression or how best to provide care for fathers. This means that symptoms of depression in new fathers often go undetected, forcing them to manage depressive symptoms on their own and leaving them feeling frustrated when they are unable to do so. The invisibility of my own depressive symptoms to healthcare practitioners frequently forced me to question the legitimacy of depressive experiences and to avoid seeking help as a result, a common experience for new fathers (Darwin et al., 2017).

Thankfully, as scholarly recognition of paternal postnatal depression has emerged, practitioners are being challenged to reconsider how they relate to new fathers. For example, the group Fathers Reaching Out actively campaigns for better understanding of fathers' mental issues and similar national campaigns have been run in the UK (McConnell et al., 2014). Health visitors, who play a key role in helping families to meet their emotional and physical needs in the UK, and family-centred practitioners more generally are now encouraged to pay closer attention to the mental health of new fathers, to seek appropriate education and training, and to more actively engage with fathers (Oldfield & Carr, 2017; Whitelock, 2016). This includes the provision of father-specific care during the antenatal period, when the anxiety and stress experienced by some fathers could be alleviated (Bergström et al., 2009; Tohota et al., 2012).

Routine screening of new fathers for depression, so that all parents are treated equally, is now being placed on the agenda (Edward et al., 2014; Paulson & Bazemore, 2010). There is concern that current screening tools used for women may not be valid for use in new fathers (Massoudi et al., 2013), but their use alongside male-specific depressive measures, such as the Male Depression Risk Scale (Rice et al., 2013), may improve screening outcomes. Programmes to promote father-inclusive health services are also beginning to emerge (Price, 2018) and, in some Sure Start Children's Centres in the UK, fathers are routinely encouraged to attend men's groups, where added support can be provided, particularly for men who may be unwilling to disclose symptoms of mental health disorders in routine postnatal care (Coleman et al., 2016; Potter & Carpenter, 2010). Extending these programmes nationally is an important next step for practitioners.

But these policy suggestions are unlikely to achieve longer-term success in the absence of broader societal challenges to constructions of fatherhood and masculinities. National and community-based educational programmes that raise awareness of, and challenge assumptions about, paternal postnatal depression are important to give new fathers the space and tools to confidently and proactively seek help when needed. Societal support, including adequate paid paternity leave (and ensuring that new fathers are supported to effectively use paternity allowances) is also important, particularly as it would give new fathers time to adjust to their new familial roles and feel more confident about managing employer expectations, family needs, and the family's economic situation (Feldman et al., 2004; Kowsellar et al., 2015).

Providing and developing community-based support networks for new fathers, which focus on the active roles of fathers and helping to relieve a reliance on partners as primary support providers, can also help to alleviate stress in the postnatal period (Kim & Swain, 2007). Providing parents with access to psychoeducational programmes that promote realistic expectations of becoming a parent and the development of psychosocial tools to strengthen positive ties to one's partner, can be very helpful in the transition to parenthood and to prevent relationship dissolution (Daley-McCoy et al., 2015). Providing opportunities that facilitate dialogue between fathers, including fathers of older babies and toddlers, could be useful especially for new fathers that lack male connections (Kumar et al., 2018). Finally, for fathers that are diagnosed with postnatal depression, ensuring adequate longer-term care is available and adequately funded is vital.

My son

The spiral of depressive episodes and symptoms is often incredibly debilitating for new fathers and we need to be much better supported. In my case, it took repeated breakdowns and the support of my wife for me to finally approach my GP for help. I am now receiving excellent therapeutic care for my depression and am in a better place a year after the birth of my son. I still occasionally struggle and I still have a lot to learn about being a good parent, but I am on the path to getting better.

Some might not like everything that I have said here, especially as my son will eventually be able to read all this. The truth is, it breaks me to know that my son will one day learn that his father was unable to cope with his arrival into the world. But I also believe that, if things are to change, we have a responsibility to be honest with our children. I never want my son to experience depression, never want him to go through what I have. But I also want him to know that if he ever does need help, both his parents will be there to support him. And I also want him to know that, in my darkest days, it was he that gave me the strength to keep fighting. In spite of the anxieties, the fear, the self-loathing, a love for my son deeper than anything I thought I'd ever know began to grow. And that love continues to evolve every day and is the reason I'm able to write this. When my son is old enough to read this, I hope he understands that I was never my depression. And that I will always love him. 

- Viren Swami is in the School of Psychology and Sport Science, Anglia Ruskin University, Cambridge, UK. [email protected]

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