Alexsia Priolo

Understanding the signs, risk factors, screening tools, and family-wide impacts of paternal postpartum depression—and how clinicians can better support fathers throughout the perinatal period.

Abstract

This article highlights paternal postpartum depression as a significantly underrecognized component of perinatal mental health. It reviews prevalence, symptom presentation, risk factors, screening recommendations, and evidence-based management strategies to help clinicians better support fathers, mothers, and infant development.

The perinatal period is a time for psychological adjustment for both parents, and mental health issues can impact both partners and their infant. While maternal mental health is a widely recognized public health concern, paternal mental health is an established yet underrecognized concern which can impact the family unit.¹

Rates of paternal postpartum depression (PPD) can range, but was found to be 8.75% during the first year postpartum², and fathers find it difficult to express their needs and desire for help, often encouraging help for their female partners instead.

Understanding Paternal Postpartum Depression

The DSM-5, does not recognize PPD as a mental health condition, and there is a lack of official criteria and defining factors, resulting in a poorly understood and under-researched condition.³ However, from what is understood, paternal postpartum depression can develop during pregnancy or within 12 months after birth, with the highest prevalence being 3-6 months postpartum.⁴

In terms of signs and symptoms, PPD may appear in different ways than expected. Rather than low mood, exhaustion, fatigue, self-criticism, irritability, restlessness, and anger may prevail.³ Men may withdraw from family, work, and social situations, they may also exhibit indecisiveness and avoidance.⁵ Alcohol and drug use, as well as partner violence may be expressions of depression.⁵ While men experience psychological distress during the perinatal period, they may question the legitimacy of their experience, and instead focus on their partner’s needs.¹

Risk Factors & Red Flags

Risk factors of developing PPD are similar to those in maternal postpartum depression and include sociodemographic, psychological, obstetric and infant, and behavioural factors, as seen in table 1. A few influencing factors for PPD were identified: unemployment, low social support, negative life events, perceived stress, financial strain, history of mental illness (identified as the strongest factor), parity, maternal postpartum depression, and lower marital relationship satisfaction.⁶

Table 1: Risk factors of developing postpartum depression⁶

Sociodemographic	Psychological	Obstetric and Infant	Behavioural
Age, ethnicity, education level, marital status, monthly income	History of depression, social support, maternal prenatal anxiety, marital relationship satisfaction	Undesired pregnancy, pregnancy with fertility treatment, full-term pregnancy, mode of delivery and infant gender	Smoking and alcohol use

Ansari⁷ identified that fathers are 2.5 times more likely to be depressed at 6 weeks postpartum, if their partner is also experiencing postpartum depression. This suggests that paternal mental health should also be assessed during prenatal visits for early identification and treatment, as fathers are expected to be a key source of support for their partners during this transition into parenthood.

Screening & Assessment

Current evidence suggests using the Edinburgh Postnatal Depression Scale (EPDS) to screen for paternal postpartum depression, as it’s a validated tool for detecting PPD with a cut-off of 10.⁸ However, the EPDS does have its limitations and using it alone may miss fathers that have postpartum depression.

A study by Kennedy and Munyan⁴ suggested that the EPDS and the Gotland Male Depression Scale (GMDS) measure different depressive symptoms, and may identify different components of depression. Their review noted that distress may be more common than depression in the 3-4 month postpartum period and may present as irritability, feelings of overwhelm, and aggression.

While no formal screening recommendations by the United States Preventative Task Force exist, the National Perinatal Association recommends screening fathers twice in the first postpartum year.⁴ However, they do not explicitly recommend when exactly the screening should occur or which tool should be used. Kennedy recommends a cut off of 10 when using the EPDS, followed by using the Patient Health Questionnaire 9 if depression is identified.⁴

Implications for Family Health and Infant Development

Father-infant bonding refers to the extent in which fathers feel positive emotions towards their child.⁷ While fathers may first begin bonding with their child when they hear their baby’s heartbeat or view them during a prenatal ultrasound, most report that bonding begins in the postpartum period. The physical contact with the child possibly immediately after birth (e.g. cutting the umbilical cord or skin-to-skin contact after a cesarean birth), participating in childrearing, and performing newborn massage are all factors that influence the bond. The father-infant bond also impacts child outcomes, executive functioning and behaviour.

When a father is impacted by PPD, this can impair that bonding relationship and negatively impact a child’s emotional and behavioural development. The World Health Organization has recognized that difficulty bonding with an infant and experiencing depression are risk factors for child maltreatment.⁸

A child may begin to act out, be diagnosed with pediatric psychiatric disorders, exhibit deﬁant/conduct disorders, and cause disruptions to partner relationships.^4,8 In addition, children are 2-4 times more likely to develop depression prior to adulthood if their parents suffered from depression.⁴

Fathers with strong coparenting relationships report fewer depressive symptoms, and less impaired bonding, decreased rejection and anger, and decreased anxiety about care. Coparenting, rather than relationship quality, is a stronger predictor of child outcomes as it focuses on the parent’s relationship to their child.⁸

Paternal depression may also lead to the risk of or worsening of symptoms of depression in mothers during pregnancy and within the first 6 months after birth.^1,9

Management Strategies

A 2017 study¹identified that men prefer to focus on the successful navigation of fatherhood and resilience, rather than treat illness. Support focused around the father’s role as a supporter and co-parent, as opposed to them being “in-need” may be more desirable for treatment.

Currently, there are no clear guidelines in the treatment of PPD. Nevertheless, we can turn to the American Psychiatric Association (APA) guidelines for the treatment of depression, especially since existing or past depression is a significant risk factor for the development of PPD.

As a first-line treatment, the APA recommends pharmacotherapy (e.g. second-generation antidepressants) or psychotherapy (e.g. cognitive behavioural therapy, mindfulness-based cognitive therapy, etc.).¹⁰ One study demonstrated that compared to pharmacotherapy, fathers prefer individual or couple psychotherapy for treatment of PPD, with a preference for individual therapy.¹¹

The APA also suggests that problem-focused couple’s therapy be recommended in the circumstance of relationship distress, over pharmacotherapy.

If pharmacotherapy or psychotherapy is ineffective or unacceptable, the APA recommends exercise monotherapy, St. John’s Wort monotherapy, or even acupuncture in combination with antidepressant medication.

Exercise & Depression: Various modalities have been shown to be well-tolerated and effective for treating depression including walking or jogging, yoga, dancing, and strength training; especially when exercise was of vigorous intensity.¹² Effects were comparable to psychotherapy or pharmacotherapy. In Canada, adults are recommended to aim for 150 minutes of activity accumulated per week, aiming for muscle strengthening activities using major muscle groups at least twice per week.¹³

St. John’s Wort (SJW) & Depression: Also known as Hypericum perforatum, St. John’s Wort is used as a botanical remedy for mental health including mild-to-moderate depression. It has been reported to decrease anxiety, neuralgia, and stress by regulating neurotransmitters within the brain.¹⁴The standard dosing regime for SJW is 900mg per day, usually divided into three doses of 300mg per day.¹⁴ To determine its effectiveness in depression, SJW should be taken consistently for 4-6 weeks.

Acupuncture & Depression: The APA recommends the combination of acupuncture and pharmacotherapy, rather than acupuncture as monotherapy. When combined with pharmacological treatment, acupuncture improves depressive symptoms and reduces the side effects of pharmaceutical treatment which is often the reason for discontinuation of pharmaceuticals.¹⁵ The selection of acupuncture points vary based on individual symptoms, but typically includes GV20, Yintang, PC6, SP6, HT7, LI4, LV3.¹⁵

Looking Ahead

Paternal postpartum depression is a growing concern, as it poses a risk to the family unit as well as the future emotional and behavioural development of the child. Naturopathic Doctors often see women throughout their perinatal journey, and therefore have the ability to inform mothers about paternal mood disorders. They can advocate for screening of paternal depression early in pregnancy, and continue to do so in the postpartum.

Should a father be diagnosed with paternal postpartum depression, naturopathic doctors can refer to psychotherapists for CBT, and potentially utilize some of the above complementary techniques to help manage and treat depression. Moreover during well-child visits, Naturopathic Doctors can check in with fathers inquiring about how parenting is going, as well as everyday routines with their child.⁸

“The Village” we often refer to when discussing postpartum care, should not only serve the mother and child, it should also serve the father. The father is often the mother’s primary support person, therefore it’s important for healthcare providers to support him in his role throughout the child’s first year of life to better improve child health outcomes.³

Dr. Alexsia Priolo is a Naturopathic Doctor in Toronto, Ontario, Canada, where she supports women in the perinatal period. She believes that women have the power to shape their future health starting in pregnancy. Alexsia has an Honours Bachelor of Science in Biology from York University and a Doctor of Naturopathy from the Canadian College of Naturopathic Medicine. She is also a Confident Clinician Perinatal Fellowship Alumni.

Instagram: @dr.alexsiapriolo.nd

References

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[2] Chen J, Zhao J, Chen X, Zou Z, Ni Z. Paternal perinatal depression: A concept analysis. Nurs Open. 2023;10(8):4995-5007. doi:10.1002/nop2.1797

[3] Bruno A, Celebre L, Mento C, Rizzo A, Silvestri MC, Stefano RD, et al. When Fathers Begin to Falter: A Comprehensive Review on Paternal Perinatal Depression. Int J Environ Res Public Heal. 2020;17(4):1139. doi:10.3390/ijerph17041139

[4] Kennedy E, Munyan K. Sensitivity and reliability of screening measures for paternal postpartum depression: an integrative review. J Perinatol. 2021;41(12):2713-2721. doi:10.1038/s41372-021-01265-6

[5] Berg RC, Solberg BL, Glavin K, Olsvold N. Instruments to Identify Symptoms of Paternal Depression During Pregnancy and the First Postpartum Year: A Systematic Scoping Review. Am J Men’s Heal. 2022;16(5):15579883221114984. doi:10.1177/15579883221114984

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[7] Ansari NS, Shah J, Dennis C, Shah PS. Risk factors for postpartum depressive symptoms among fathers: A systematic review and meta‐analysis. Acta Obstet Gynecol Scand. 2021;100(7):1186-1199. doi:10.1111/aogs.14109

[8] Wells MB, Jeon L. Paternal postpartum depression, coparenting, and father-infant bonding: Testing two mediated models using structural equation modeling. J Affect Disord. 2023;325:437-443. doi:10.1016/j.jad.2022.12.163

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[10] American Psychological Association. (2019). Clinical practice guideline for the treatment of depression across three age cohorts. Retrieved from https://www.apa.org/depression-guideline.

[11] Cameron EE, Hunter D, Sedov ID, Tomfohr-Madsen LM. What do dads want? Treatment preferences for paternal postpartum depression. J Affect Disord. 2017;215:62-70. doi:10.1016/j.jad.2017.03.031

[12] Noetel M, Sanders T, Gallardo-Gómez D, Taylor P, Cruz B del P, Hoek D van den, et al. Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials. BMJ. 2024;384:e075847. doi:10.1136/bmj-2023-075847

[13] Ross R, Chaput JP, Giangregorio LM, Janssen I, Saunders TJ, Kho ME, et al. Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep1. Appl Physiol, Nutr, Metab. 2020;45(10):S57-S102. doi:10.1139/apnm-2020-0467

[14] Zhao X, Zhang H, Wu Y, Yu C. The efficacy and safety of St. John’s wort extract in depression therapy compared to SSRIs in adults: A meta-analysis of randomized clinical trials. Adv Clin Exp Med. 2022;32(2):151-161. doi:10.17219/acem/152942

[15] Yang NN, Lin LL, Li YJ, Li HP, Cao Y, Tan CX, et al. Potential Mechanisms and Clinical Effectiveness of Acupuncture in Depression. Curr Neuropharmacol. 2022;20(4):738-750. doi:10.2174/1570159×19666210609162809

Bio

Dr. Alexsia Priolo is a Naturopathic Doctor in Toronto, Ontario, Canada where she supports women in the perinatal period. She believes that women have the power to shape their future health starting in pregnancy. Alexsia has an Honours Bachelor of Science in Biology from York University, and a Doctor of Naturopathy from the Canadian College of Naturopathic Medicine. She is also a Confident Clinician Perinatal Fellowship Alumni.