Significant depression affects between 10% and 30% of women during pregnancy: the incidence remains elevated in the year following childbirth.1,2 Although a large body of research has documented the risk factors for and negative effects of depression in mothers, little is known about depression in expectant or new fathers.3
This article reviews the limited but growing literature about prenatal and postpartum depression in fathers. It highlights recent findings, identifies areas for future research, and suggests a preliminary conceptual framework that emphasizes the co-parental relationship. The goal is to improve our understanding of relational factors that may underlie depression in new fathers.
Does childbirth-associated depression affect fathers?
Depression during pregnancy and following childbirth has been historically regarded as a phenomenon that affects only women.2,4 The popular press as well as medical and mental health providers emphasize the causative role of biochemical changes that the mother experiences during pregnancy and following birth. Endocrine and biochemical theories of childbirth-associated depression in women, despite their popularity, are supported by a fragmented literature that inconsistently identifies hormonal causes and insufficiently replicates hormone-depression correlations.5
Psychosocial theories of prenatal and postpartum depression place the causal focus on stresses in the mother that are triggered by relational disturbances (eg, gender role demands, unsatisfied attachment needs, disruptions in interpersonal relationships, perceived dissonance with social norms).6 Research on psychosocial factors has been relatively fruitful and has identified significant predictors of depression that include life stress, lack of social support, a difficult marital relationship, socioeconomic status, and many other psychological, familial, and social predictors.7-10
It is unclear why depression in new and expectant fathers has not been examined until recently. The popular tendency to focus on biological changes that surround the pregnancy as causal factors may have contributed to overlooking the nonpregnant parent. Fathers (who are not directly susceptible to childbirth-related biochemical changes) are subject to psychosocial stressors that accompany new parenthood and, therefore, they may experience distress uniquely tied to their new role. The quantity and quality of the father’s involvement with his infant or toddler has been demonstrated to predict child developmental outcomes. Paternal depression during a child’s early years may convey developmental and psychological risks to the child.11,12
A number of recent studies have documented that depression in new fathers is both prevalent (ie, the incidence is higher than in the general adult male population) and associated with negative outcomes for the offspring. In the months following childbirth, the incidence of significant depression among fathers has been estimated to be between 1.2% and 25.5%.13-15 This budding field of research is not without growing pains, and the wide range of incidence estimates is a clear signal of this. Methods for measuring depression in new and expectant fathers have yet to reach consistency among researchers. We remain far from a consensus on such issues as:
• When to measure (during pregnancy and/or after the birth of the child)?
• How to identify which fathers to include?
• How to sort out subgrouping is-sues (eg, resident vs nonresident fathers)?
We still lack the terminology even to describe the phenomenon (eg, male postpartum depression or early fatherhood depression).
The wide variance in methods used to study early fatherhood depression is a probable cause of the variable prevalence estimates that have been reported by Goodman, Pinheiro, myself, and others.13-15 Despite these challenges, however, it has become clear that depression in expectant and new fathers is more common than we once believed.
Consequences of depression
Depression in new mothers is a major concern because it negatively affects the child’s development and mental health outcomes.3 Little is known about the effect of a father’s depression on the child. However, a number of studies suggest that paternal depression does present a risk to healthy child development. A 2005 study found that increases in paternal depression symptoms measured at 8 weeks’ postpartum were associated with increased child internalizing and externalizing behavior problems at 3.5 years. This effect, which was stronger in boys, was observed in children even when paternal depression had diminished.16 Other findings suggest that depression in fathers of infants is associated with reduced father-child activ-ities, impaired father-child bonding, increased parenting stress, and greater discord in the relationship with the child’s mother.17,18 In several studies, subclinical elevations in depressive symptoms were associated with negative effects on parenting and negative consequences on child functioning.15,19
A study undertaken by me and my colleagues found that 9-month-old children of depressed fathers experienced a reduction in positive parent-child interactions (including playing, singing songs, telling stories, and reading).15 New findings suggest that this reduction in father-child interaction, particularly with respect to reading, negatively affects child expressive vocabulary at 2 years of age.19 Moreover, depression among nonresident parents has a negative effect on the parental relationship and subsequently reduces the involvement of the nonresident father with his infant.15,19
Factors that cause or contribute to depression in new fathers are poorly understood. As with depressive risk in general, a history of depression and other mental illness appears to be a strong predictor of postnatal depression in both fathers and mothers.20 Although family structural characteristics (such as separation, divorce, or stepfamily status) appear to be risks for greater depression, specific proximal mechanisms leading to early paternal depression are unclear.21,22
Maternal depression and paternal depression are consistently associated. Several studies have found a slight to moderate correlation in depressive symptom severity between mothers and fathers. Disruption in the co-parenting relationship appears to be a meaningful mechanism for this depressive contagion among new parents. The odds of significant paternal depression increased 3-fold when the mother experienced mild depression and increased to more than 8-fold when the mother experienced moderate to severe depression.13-15 One study investigated the correlates of paternal depression in the first postnatal year. The father’s depressive symptom severity, rather than being influenced predominantly by other personality characteristics, was predicted primarily by the mother’s neuroticism, depressive symptoms, and the quality of the marital relationship.23
Beyond being a phenomenon of depressive contagion within romantically involved couples, we found a slight to moderate correlation in levels of depressive symptom severity when the new parents do not live together (eg, they are divorced, separated, or have never lived together). Depression, in this context, negatively affects the parenting relationship and the involvement of the nonresident father.22 Findings from other studies of nonresident parents also suggest that depressive contagion extends beyond the context of traditionally cohabiting couples.24,25
Toward a relationally specific conceptual model
No model has yet been proposed to explain early paternal depression, nor has an explicit relational model been suggested to address the coevolution of childbirth-related depression in mothers and fathers. As we learn more about paternal depression during early parenthood and this becomes accepted as a significant individual and family issue, the need for a more integrated and relational approach becomes apparent.26 A clear model is needed to understand the role of parental relationship disturbance on depression as well as the influence of one partner’s depression on the other.27
By combining 3 distinct conceptual approaches, a framework to describe early parental depression from a relational perspective emerges. The first framework, proposed by Simpson and colleagues,28 uses adult attachment theory. Developed with maternal depression in mind, their work suggests that a successful transition to motherhood is mediated by a strong intimate relationship with her partner and associated support. This is based on the premise that successful and resilient intimate relationships buffer an individual’s vulnerability to life stressors.29
Belsky and Rovine30 found that perceived marital love and intimacy declined linearly across the 3 years following the transition to parenthood (with a sharper quadratic decline for new mothers), while marital ambiva