In this issue of American Family Physician, Langan and Goodbred review the identification and management of perinatal depression in women.1 Although new fathers are at lower risk of depression than are new mothers,2 the prevalence of depression in new fathers is higher than that in the general population.3 Depression occurs in 10% of men from their partner's first trimester to one year postpartum; three to six months after birth is a particularly sensitive period of increased symptoms.2 Fathers who live with their children do not have a history of increased depressive symptoms prior to having a child but are at increased risk of depressive symptoms from birth through the first five years of life.4
Perinatal depression in fathers can be attributed to psychosocial risk factors, including a history of depression that increases vulnerability to recurrent symptoms, stress of raising children, role changes, interparental conflict, and financial concerns.5 Maternal depression is moderately correlated with paternal depression during the perinatal period,1 likely because depression in one partner can impact the other's mood. In turn, after accounting for the effects of maternal depression, paternal postnatal depression has a longitudinal impact on parenting practices (e.g., less reading, more corporal punishment),6 the child internalizing behaviors (e.g., anxiety) and externalizing behaviors (e.g., misbehavior, school performance),7 and the family environment (e.g., interparental conflict).8,9
While the maternal-child health care system routinely screens for perinatal depression in mothers, fathers are increasingly also involved in all aspects of their child's care, including attending well-child visits.10 Opportunities for identifying fathers with depression can occur at the mother's prenatal visits and postnatal check-up, or during newborn and infant clinical encounters. The Edinburgh Postnatal Depression Scale (EPDS; available at https://www.aafp.org/afp/2010/1015/p926.html#afp20101015p926-f1) is commonly used to screen for depression in new mothers and has been validated for assessing postnatal depression in fathers using a cutoff of 10 points.11 Even if the father does not attend such visits, the EPDS has been adapted and validated as a proxy screening for paternal depression through the report of the mother.12 A positive screening result based on the mother's proxy report (score of 5 or more) would indicate a follow-up screening test with the father directly. Early detection can offset the risk of chronic depression.
Traditional screening measures have been found to underreport depressive symptoms in men, and men are inclined to mask their symptoms through avoidant or numbing behaviors (e.g., aggression, alcohol or drug use).5 Measures of “masculine depression,” such as the Masculine Depression Scale13 and Male Depression Risk Scale,14 can supplement traditional depression measures.
Once perinatal depression is diagnosed in a father, interventions include pharmacotherapy, psychotherapy, or a combination. Treatment recommendations should be tailored based on depression severity and factors that would affect compliance (e.g., time constraints for attending therapy, medication adverse effects).
Effective psychotherapy approaches include cognitive behavior therapy, mindfulness-based therapies (e.g., acceptance and commitment therapy), and interpersonal psychotherapy.15,16 Selective serotonin reuptake inhibitors are first-line pharmacotherapy options. These medications can have adverse effects, however, including sexual dysfunction, which is even more likely in men than in women (62% vs. 57%, respectively).17 The adverse effects of selective serotonin reuptake inhibitors can be barriers for some men, so a discussion of the benefits, adverse effects, and alternatives may maximize compliance.
Depression screening tests do not differentiate between unipolar and bipolar depression. Bipolar disorder includes the hypomanic or manic symptoms of euphoria, increased energy, or persistent irritability. Physicians should ask about a history of these symptoms before prescribing an unopposed antidepressant. The Mood Disorder Questionnaire (available at http://www.dbsalliance.org/pdfs/MDQ.pdf) is a brief screening instrument for lifetime hypomanic episodes18 that has been validated during the postnatal period.19
Just as the past few decades have brought advances in the identification and treatment of maternal perinatal depression, the coming decades are likely to bring gains in these areas for paternal depression. Ample opportunities exist across the health care spectrum to identify and treat paternal depression to improve health outcomes of parents and children.