Supporting fathers’ mental health in the perinatal period

Cat Strawa (AIFS), Melissa Willoughby (AIFS), A/Prof Rachel Dryer (ACU), Dr Robyn Brunton (CSU) and Carol Dabb (ACU), Australia, March 2024

Resource Summary

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Key messages

  • Many fathers experience worries and concerns during the perinatal period. For some fathers, these worries develop into clinical symptoms of anxiety or depression and negatively impact on father and child wellbeing, father–child relationships, couple relationships and family functioning.
  • Certain factors are associated with fathers’ likelihood of experiencing mental health challenges during the perinatal period. These include having pre-existing mental health challenges, using avoidance to cope with stress, sleep problems and maternal mental health challenges.
  • Fathers report that they can feel excluded during maternal antenatal care and have difficulties finding perinatal mental health services for fathers.
  • There is emerging evidence that interventions such as psychoeducation, cognitive behavioural therapy and mindfulness programs can support fathers experiencing mental health challenges in the perinatal period.
  • Fathers may better engage with interventions and supports delivered in group settings or online.
  • Fathers are also more likely to engage with interventions that are advertised as building practical skills rather than addressing mental health difficulties.
  • Routine mental health screening during the perinatal period is an important part of identifying fathers who are experiencing mental health challenges.
  • To support fathers in the perinatal period, practitioners can use family-inclusive approaches to perinatal mental health, encourage fathers to build social supports and use paternity leave, consider the influence of gender-based assumptions on fathers, and provide fathers with evidence-informed resources on mental health and the transition to fatherhood.

Introduction

Pregnancy is a significant transitional period for parents, frequently experienced with joy and happiness (Deave & Johnson, 2008). However, pregnancy and the first year of a child’s life (i.e. the perinatal period) can also be a time of increased uncertainty (Osofsky et al., 1985) and an opportunity for fears, worries and concerns to develop (Dryer & Brunton, 2021). For some parents these fears and worries develop into significant mental health challenges.

Perinatal mental health concerns (e.g. pregnancy anxiety, antenatal depression and postnatal depression) are more widely recognised in mothers (Dabb, Dryer, Brunton, Yap, & Roach, 2022). However, fathers can also face mental health challenges during this time and in the early years of their child’s life. Fathers are more likely than men who aren’t fathers to experience mental health challenges (Macdonald et al., 2020). There is currently limited information on the prevalence of perinatal anxiety and depression in Australian men. Yet it’s estimated that 10–13% of men experience depression in the perinatal period (Cameron, Sedov, & Tomfohr-Madsen, 2016; Da Costa et al., 2017; Paulson & Bazemore, 2010). With regards to anxiety, it’s estimated that 3.4–25% of fathers experience increased anxiety during the antenatal period, and 2.4-51% during the postnatal period (Philpott, Savage, FitzGerald, & Leahy-Warren, 2019). This can impact on child health and wellbeing as children of fathers with depression are more likely to experience developmental and behavioural problems, and psychiatric disorders (Gentile & Fusco, 2017). Untreated mental health disorders in fathers can also negatively impact on couple relationships, and family functioning and wellbeing (Bruno et al., 2020). Supporting the mental health of fathers in the perinatal period can therefore benefit both fathers and their families.

This resource explores fathers’ mental health and support needs in the perinatal period and examines how practitioners can support fathers. It discusses the needs and experiences of cisgender, heterosexual fathers as the research literature focuses on this type of father. However, we acknowledge that practitioners may also work with fathers and non-birthing parents who may be gender diverse or don’t identify as a ‘father’.

Domestic and family violence can be more likely to occur during the perinatal period (Hahn, Gilmore, Aguayo, & Rheingold, 2018). This resource doesn’t explore domestic and family violence; however, other resources related to this type of violence are listed in the Further reading and related resources section of this resource.

What are fathers’ fears, worries and mental health concerns during the perinatal period?

Fears, worries and concerns are a common part of the developmental journey for people as they transition to parenthood (Kowlessar, Fox, & Wittkowski, 2015). These fears, worries and concerns serve an adaptive function for many men (e.g. motivating them to prepare for the future) (Leahy, 2002). However, for some expectant fathers these fears, worries and concerns become excessive, and develop into clinically significant anxiety symptoms (Philpott et al., 2019). This can include persistent thoughts about the possibility of bad things happening, nervousness, irritability, sleep disturbances and restlessness (Leahy, 2002).

The anxiety experienced by fathers during pregnancy is frequently characterised by pregnancy-related concerns and is known as ‘paternal pregnancy-related anxiety’. Core components of paternal pregnancy-related anxiety include excessive fears, worries and concern about:

  • childbirth and fulfilling a support role during childbirth
  • the health and wellbeing of their baby and partner
  • post-birth changes to relationships and lifestyle
  • increased responsibility of fatherhood; and
  • their partner receiving good medical care (Dabb et al., 2022).

Experiencing anxiety in the perinatal period can impact other areas of fathers’ health and wellbeing. Paternal anxiety symptoms during pregnancy are associated1 with sleep difficulties (Finnbogadóttir & Persson, 2019), low positive affect and increased depressive symptoms (Biehle & Mickelson, 2011). Fathers with high anxiety symptoms (which may or may not be pregnancy-related concerns) during pregnancy are more likely to experience persistent fatigue (Tzeng, Teng, Chou, & Tu, 2009), reduced self-efficacy (Pinto, Figueiredo, Pinheiro, & Canário, 2016), lower responsiveness to their newborns (Parfitt, Pike, & Ayers, 2013) and higher parenting stress (Pinto et al., 2016) after the birth of their child.

Some fathers’ worries in the perinatal period can develop into clinical symptoms of anxiety. They can also experience changes to their mood, including symptoms of depression. In Australia, men who are fathers of infants are more likely than men who aren’t fathers to experience more severe depressive symptoms and anger (Macdonald et al., 2020). Some men may also experience distress due to a conflict between some fathering behaviours (e.g. soothing, hugging) and what they have been socialised to view as ‘acceptable’ masculine behaviours and emotions (e.g. anger) (Singley & Edwards, 2015). Paternal depression may adversely impact parent–infant interactions after the child is born (Fisher et al., 2021) and the health, wellbeing and development of their children. For example, depressed fathers may be more likely to use physical punishment and less likely to read to their children at 12 months (Davis, Davis, Freed, & Clark, 2011). Moreover, paternal postnatal depression is associated with behavioural and emotional problems in their children at 4–5 years of age (Fletcher, Feeman, Garfield, & Vimpani, 2011) and 7 years of age (Ramchandani et al., 2008).

1 Associated refers to there being a relationship between two factors and when one factor changes, there is also a change in the other factor.

What factors may influence or change fathers’ mental health in the perinatal period?

In both international and Australian research evidence the following factors (i.e. behaviours or circumstances) have been identified as being associated with fathers’ likelihood of experiencing mental health challenges during the perinatal period:

  • Coping with stress through avoidance (Livingston et al., 2021)
  • Sleep problems (Macdonald et al., 2021; Wynter et al., 2020)
  • Maternal anxiety and depression (Edward, Castle, Mills, Davis, & Casey, 2015; Glasser & Lerner-Geva, 2019; Philpott et al., 2019; Thiel, Pittelkow, Wittchen, & Garthus-Niegel, 2020)
  • Prior or existing paternal mental health challenges (Philpott et al., 2019).

Table 1 outlines these factors in more detail and highlights the associated mental health challenges.

There is also emerging evidence that relationship factors (e.g. low levels of marital satisfaction or relationship quality) (Edward et al., 2015; Glasser & Lerner-Geva, 2019; Philpott et al., 2019), difficult experiences of fatherhood (e.g. impaired paternal and newborn bonding, misalignment between expectations and reality of parenthood) (Edward et al., 2015; Philpott et al., 2019), and paternal socio-demographic characteristics (e.g. being unemployed, lower education levels) (Edward et al., 2015; Philpott et al., 2019) may also be associated with fathers experiencing mental health challenges in the perinatal period.

Table 1. Factors that may influence fathers’ mental health in the perinatal period*

Type of factor

Factor

Influence on fathers’
mental health

Reference

Strategies fathers use to cope with stress Avoidance (e.g. watching TV to distract from crying)
  • Increase in paternal depression
  • Increase in any mental health challenges
Livingston et al. (2021)
Approach-orientated (e.g. soothing a crying child)
  • Increase in positive affect (e.g. positive mood and emotions)
Livingston et al. (2021)
Sleep Sleep problems (e.g. sleep disturbance, sleep quality, sleep quantity, sleep efficiency, sleepiness and fatigue)
  • Increase in paternal depression
  • Increase in paternal anxiety
  • Increase in stress
  • Increase in any mental health challenges
Macdonald et al. (2021); Wynter et al. (2020)
Maternal mental health challenges Maternal depression (including in the perinatal period)
  • Increase in paternal depression
Edward et al. (2015); Glasser and Lerner-Geva (2019); Philpott et al. (2019); Thiel et al. (2020)
Maternal anxiety in the perinatal period
  • Increase in paternal anxiety
Philpott et al. (2019)
Prior or existing paternal mental health challenges Depressive symptoms in the perinatal period
  • Increase in paternal anxiety
Philpott et al. (2019)
Post-traumatic stress disorder in the perinatal period
  • Increase in paternal anxiety
Philpott et al. (2019)
Anxiety sensitivity (i.e. fear of behaviours or sensations related to experiencing anxiety) in the perinatal period
  • Increase in paternal anxiety
Philpott et al. (2019)
Anxiety at an earlier time in the perinatal period
  • Increase in paternal anxiety
Philpott et al. (2019)
Stress in the antenatal period
  • Increase in paternal anxiety
Philpott et al. (2019)
History of depression or anxiety
  • Increase in paternal depression
Edward et al. (2015); Glasser and Lerner-Geva (2019)

*Only factors that have been identified by multiple research studies as being associated with fathers mental health are reported in the table. Some reviews have identified other factors that may impact fathers’ mental health (Edward et al., 2015; Glasser & Lerner-Geva, 2019; Philpott et al., 2019); however as the evidence on these factors is still emerging, they are described in body text only.

Although fathers who experience one or more of these factors will not necessarily experience mental health challenges, these factors are common among fathers who do experience mental health challenges in the perinatal period. Therefore, the presence of these factors may indicate an increased risk of mental health challenges for fathers.

Additionally, as most research on risk factors for fathers’ mental health challenges in the perinatal period focuses on depression or anxiety (Edward et al., 2015; Glasser & Lerner-Geva, 2019; Macdonald et al., 2021; Philpott et al., 2019; Thiel et al., 2020) we know little about how different factors may impact other mental health challenges. Further research is needed to identify the risk factors for mental health challenges other than depression or anxiety for fathers.

What are fathers’ experiences of seeking support for their mental health in the perinatal period?

Although expectant fathers may be aware of their increasing anxiety and depression during the perinatal period, some fathers don’t seek help from support services. There are several reasons for a lack of engagement, including fear of the stigma associated with mental health conditions (e.g. postnatal depression) (Letourneau, Duffett‐Leger, Dennis, Stewart, & Tryphonopoulos, 2011) and feeling pressure to conform to masculine norms of stoicism and independence (Livingston et al., 2021). This can result in fathers deciding not to seek support, using avoidant coping strategies (which is a risk factor for mental health challenges, as described above) (Livingston et al., 2021), or misidentifying their symptoms of anxiety and depression as everyday reactions to financial and health concerns or other life stressors (Letourneau et al., 2011; Pedersen, Maindal, & Ryom, 2021).

A potential barrier to men accessing and receiving mental health support in the perinatal period may be related to how they talk about their mental health. Presentations of anxiety and depression can be different between men and women (Austin, Highet, & Group, 2017). For example, men are more likely than women to describe their psychological distress as ‘stress’ or being ‘overwhelmed’ rather than as anxiety or depression (Darwin et al., 2017; Schuppan, Roberts, & Powrie, 2019). Core symptoms of men’s experiences include exhaustion, poor concentration, anger and irritability (Austin et al., 2017; Darwin et al., 2017).

Additionally, expectant fathers frequently report feeling excluded or ignored during routine antenatal care provided to their partners (Dabb et al., 2022). This lack of inclusivity can lead to fathers feeling discouraged from seeking support for their mental health (Dabb et al., 2022; Darwin et al., 2017; Letourneau et al., 2011). There’s also evidence that fathers may not seek help because they are concerned it will disrupt the services/support needed by their partners (Dabb et al., 2022; Darwin et al., 2017). However, even when fathers acknowledge that they need support for anxiety and depression, they report difficulty in finding relevant mental health services such as a health care professional with relevant expertise or experience in paternal perinatal mental health (Hambidge, Cowell, Arden-Close, & Mayers, 2021; Pedersen et al., 2021).

What interventions exist to support fathers’ mental health in the perinatal period?

There is emerging evidence to support the positive effects of a range of interventions for fathers experiencing anxiety and depression in the perinatal period (Rodrigues, Ericksen, Watson, Gemmill, & Milgrom, 2022). These interventions include therapies aimed at psychoeducation and normalising the transition to parenthood, training on lifestyle factors (e.g. sleep, nutrition, and physical activity), co-parenting relationships, and attachment skills (Rodrigues et al., 2022). There is also evidence to indicate that cognitive behaviour therapy (CBT) is effective for fathers with postnatal depression (O’Brien et al., 2017).

More recently, mindfulness-based parenting programs have been found to effectively reduce depressive symptoms in fathers, with parents who have completed these programs developing more adaptive coping strategies in response to challenges during the perinatal period (Bruno et al., 2020). There is also emerging evidence to suggest that midwife-led counselling for expectant fathers can reduce fathers’ childbirth fears (i.e. a facet of paternal pregnancy-related anxiety) (Ghaffari, Elyasi, Mousavinasab, & Shahhosseini, 2022). The advantages of this intervention approach are that midwives are likely to have close relationships with the expectant mothers and their families.

The way interventions are delivered can also influence their effectiveness and engagement of fathers. Evidence suggests that online delivery of interventions such as CBT and midwife-led counselling can increase accessibility and facilitate fathers’ engagement (Ghaffari et al., 2022; O’Brien et al., 2017). Male-only group settings may also support father’s engagement when delivering CBT (O’Brien et al., 2017). Furthermore, some research shows that programs advertised as practical skills building, rather than focusing on men’s emotional needs, were more effective at engaging fathers (Matthey, Reay, & Fletcher, 2009).

Men’s engagement with certain interventions and delivery methods can also be influenced by social norms, stigma and gender-based assumptions (Livingston et al., 2021; Rodrigues et al., 2022). For example, an Australian survey identified that some men felt pressure to be self-reliant when managing problems, which may align with men’s preferences for accessing supports via the internet, as they can be more private and easily accessed (Giallo, Dunning, & Gent, 2017).

However, there are some limitations to the current evidence on interventions to support fathers’ mental health in the perinatal period. Despite the increased interest in paternal mental health, few interventions have been specifically designed for fathers experiencing difficulty with the transition to fatherhood (O’Brien et al., 2017) or for fathers with clinical levels of depression and anxiety symptoms (Rodrigues et al., 2022). Interventions have predominantly been designed for fathers or parents generally, regardless of whether they had a clinical mental health diagnosis. Therefore, it can be difficult to know whether some of these interventions can reduce the mental health challenges of fathers who are experiencing clinical symptoms, as opposed to supporting the wellbeing of all fathers (including those without clinical symptoms).

Another limitation of existing evidence is that very little research has been conducted with fathers from culturally and linguistically diverse communities, lower socio-economic backgrounds or LGBTIQA+ families (Livingston et al., 2021; Philpott et al., 2019). This means that we have limited understanding of the unique mental health challenges experienced in the perinatal period by these fathers or how to best support them (Livingston et al., 2021; Philpott et al., 2019).

How can practitioners and services support fathers during the perinatal period?

How can practitioners and services support fathers during the perinatal period?

Screening fathers for mental health concerns

There is good evidence that routine mental health screening is important for both fathers and mothers in the perinatal period (Edward et al., 2015; Livingston et al., 2021; Rodrigues et al., 2022; Rollans, Kohlhoff, Meade, Kemp, & Schmied, 2016). Research on screening for paternal mental health symptoms suggests the following:

  • Mental health screening can help practitioners identify which fathers may need more support in the perinatal period. Screening men for experiences of exhaustion, poor concentration, anger and irritability (Austin et al., 2017; Darwin et al., 2017) may be helpful as fathers don’t always describe their psychological distress as experiences of anxiety or depression (Darwin et al., 2017; Schuppan et al., 2019).
  • Practitioners should consider using appropriate and validated tools to screen for paternal depression in the perinatal period (Rodrigues et al., 2022; Shafian, Mohamed, Nasution Raduan, & Hway Ann, 2022). For example, the Edinburgh Postnatal Depression Scale has been validated for use with fathers, with a lower cut-off score of 5 or 6, as opposed to 7 or 8 in mothers (Matthey, Barnett, Kavanagh, & Howie, 2001).
  • When mothers have positive screens for mental health challenges, fathers should also be engaged and offered screening because maternal mental health challenges are a risk factor for fathers’ mental health concerns (Thiel et al., 2020).
  • Screening fathers for a high level of avoidant coping strategies (a risk factor for paternal mental health challenges) may help identify those who are at risk of, or currently experiencing, mental health challenges (Livingston et al., 2021).
  • Asking postpartum fathers about their sleep may help to create a safe, non-stigmatising space for practitioners to ask them about their mental health and wellbeing as poor sleep is associated with paternal mental health concerns (Macdonald et al., 2021).
  • Some screening may need to occur separately for mothers and fathers. For example, confidential screening for intimate partner violence with mothers. However, where possible fathers should be involved in, or provided with, separate psychosocial screening as it creates an important opportunity for them to discuss their mental health concerns (Rollans et al., 2016).

Engaging and supporting fathers in the perinatal period

In addition to mental health screening for fathers, research evidence suggests the following considerations and approaches can be useful when engaging and supporting fathers during the perinatal period:

  • Reassure fathers of the legitimacy of their experience and provide support and information that is framed around the transition to fatherhood. Information that includes references to stress and overwhelm may resonate more with fathers than an exclusive focus on mental health disorders and their symptoms (Darwin et al., 2017).
  • Involving and engaging fathers during the delivery of routine antenatal and postnatal care will help fathers feel less excluded from this care (Dabb et al., 2022; Letourneau et al., 2011; Pedersen et al., 2021). Greater involvement of fathers in the delivery of perinatal care also provides more opportunity for health care professionals to complete mental health screening and support help-seeking behaviours (Pedersen et al., 2021; Schuppan et al., 2019).
  • Family-inclusive approaches to perinatal mental health can support practitioners to include fathers when developing or delivering perinatal mental health programs (Gentile & Fusco, 2017).
  • To increase fathers’ engagement in programs and services:
    • Offer online and group engagement options where appropriate (Ghaffari et al., 2022; Giallo et al., 2017; O’Brien et al., 2017).
    • Consider approaching men through services that they or their partner are already attending (Matthey et al., 2009).
    • Directly ask men to participate in a single session (initially) rather than multiple session programs (Matthey et al., 2009).
    • Advertise programs as building practical skills rather than focusing on supporting men’s emotional needs (Matthey et al., 2009).
    • Keep in mind that social norms and gender-based assumptions may influence men’s engagement and how comfortable they feel accessing services (Giallo et al., 2017; Livingston et al., 2021; Seymour et al., 2021).
  • Practitioners can connect fathers to peer support groups or encourage them to build their own social support network. Some fathers have reported that they want to make social contact with other fathers but lack the opportunity to do so (Rodrigues et al., 2022; Seymour et al., 2021).
  • Paternal leave can be supportive of mental health, so practitioners can encourage fathers to use their paternity leave entitlements (Philpott et al., 2019). Despite many men wanting to take paternal leave, the use of this leave by Australian fathers is low (Walsh, 2019). Paternal anxiety is less common in countries that have generous paternity leave policies compared to countries with minimal paternity leave options (Philpott et al., 2019).

Conclusion

Supporting fathers in the perinatal period is important for their mental health and the wellbeing of their families. Fathers may experience fears, worries and concerns as a normal part of the perinatal period; but for some fathers these concerns become mental health challenges. Some fathers experiencing challenges may also not engage in help-seeking behaviours, or will use avoidant coping strategies, because they fear the associated stigma or misidentify their own symptoms. Help seeking can be further impacted by fathers feeling excluded or ignored during antenatal care or by concerns they may draw attention away from their partner’s need for care and support.

To support fathers’ engagement with services, practitioners can engage and screen fathers during the delivery of routine perinatal care, use family-inclusive approaches and consider the way programs are delivered and advertised. Fathers can also benefit from evidence-based information about the transition to fatherhood, social support and accessing parental leave.

Current interventions to improve fathers’ wellbeing include therapy, training and education, and mindfulness-based training programs. However, there is still a need for more evidence about which interventions are most effective, especially for fathers with clinical mental health challenges.

How this resource was developed

This resource was developed as part of a series of resources focusing on fathers’ engagement in parenting and child mental health. These resources synthesise the findings of a rapid literature review that searched for international peer reviewed research articles on fathering and child mental health. As part of this review, Melissa Willoughby and Cat Strawa searched for terms relating to fathering, child mental health, promotion and interventions in Medline, PsycInfo and Web of Science from 1 January 2012 to 30 May 2022. Relevant, peer-reviewed literature published in English and conducted in high-income, English-speaking countries were included.

This resource also draws on the findings of a systematic literature review conducted by Carol Dabb, Rachel Dryer, and Robyn Brunton on paternal pregnancy-related anxiety (Dabb et al., 2022). Rachel Dryer also conducted a search related to paternal anxiety and depression and effective interventions.

In developing this and other related resources, Melissa Willoughby and Cat Strawa consulted with eleven practitioners, service leaders and researchers who are experts in parenting, fathering, and men’s and child health. Insights from consultations were used to guide the scope and resources from the review.

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