I’m afraid I think that you miss the point, Ed. Of course it’s not wise to overmedicalise normality BUT it IS important to recognise and act when things are not okay.

In your entertaining blog post you accurately point out that although the vast majority of modern fathers experience sleep-deprivation, irritation, a degree of helplessness, and a sexual-intimacy drought in the post partum period, these are most likely not the symptoms of depression. That’s exactly what the JAMA study says. In this meta-analysis of studies of the prevalence of pregnancy-related and post-partum depression among men and women in the community, the rate of NO depression between the first trimester and 1 year postpartum in fathers was 89.6%. (1)

The important point, though, is that an estimated 10.4% were pretty likely to be depressed (even more if you look only at studies that used a proper interview tool). That IS a big deal because the usual 12 month prevalence of depression in men in that age group is 4.8% and, as the authors of the JAMA article say, this more-than-doubling of the usual prevalence of depression represents ‘a significant public health concern’. What makes it a public health concern is what we know about the longer term consequences of true postpartum depression. There’s more evidence about down-the-line consequences of maternal perinatal depression than about the effects of depression in fathers.

Mums who are depressed either in pregnancy or the post partum are more likely to have had depression before and more likely to go on to have recurrent episodes of depression (throughout their offspring’s childhoods). Mothers’ perinatal depression has been shown in prospective studies to be associated with psychological and behavioural problems in their children. Prospective studies began to be published in 2006 that demonstrated an association between exposure to mums’ post partum depression and diagnosed affective disorder in young teens (2). In one smallish long term follow up study of mother child pairs in London, UK, with excellent follow up, mothers were recruited in pregnancy and diagnoses of depression were made using a validated interview tool. In that study 16 year old children of mothers who were depressed in the peripartum were over four times more likely to be diagnosed with depression themselves in adolescence than 16 year old children of mothers who weren’t depressed in the peripartum. (3).

How do fathers factor into this mix? Less is known. A prospective population-based study of families from a large birth cohort showed that probable depression in fathers during the postnatal period (8 weeks post partum) was associated with “adverse emotional and behavioural outcomes in children aged 3•5 years (adjusted odds ratio 2•09, 95% CI 1•42—3•08), and an increased risk of conduct problems in boys (2•66, 1•67—4•25)”, an effect that remained significant even after the authors controlled for maternal postnatal depression and subsequent paternal depression (at 21 months post partum). (4)
These findings need careful validation because the instrument used to ‘measure’ postnatal depression in this case was the Edinburgh Postnatal Depression Score, which is a) a screening and not a diagnostic tool, and b) not validated as a screening tool in men. However, some of the studies included in the recent JAMA meta-analysis used the EPDS and, rather interestingly, the EPDS seemed generally to find lower rates of paternal post partum depression than proper diagnostic interview tools did. I guess it’s just a matter of time before there’s evidence to show that paternal mood disorders are independently associated with more long term effects.

Of course, finding an association between parental depression during offspring’s early childhoods, and ‘Bad Behaviour’ and mood disorder later on in kids, tells us nothing about whether treating the parents’ depression prevents or delays these consequences in their children (although our recent clinical review on adolescent depression would seem to suggest that it might) (5). Still, I would argue that in the light of what we know it is wise to identify the slightly-more-than-10% of men who may have genuine postnatal depression, make a diagnosis and get them proper treatment.

Ed, you say, ““I can’t help feeling that a large part of what we have in these reports is a nasty case of giving a medical label to the more fundamental reality of one’s life being turned on its head.” I disagree. Life turns on its head for all but the most privileged few following the arrival of a kid. 90%, like you, balk, adapt and then move on and laugh about it later. 10% hit the wall that is depression and can’t get over it without help and we need to find out who those people are because it isn’t just them who suffer in the long term. Perhaps, as you suggest, a bit of preparation might help both groups (although there really isn’t a lot of evidence about the usefulness of any intervention to prevent either culture shock or depression).

I don’t think that researchers who are looking at postpartum depression are equating “the desperate need for a good night’s sleep” with depression as you do. You clearly aren’t and weren’t depressed after your kids arrived and so you don’t know what being depressed equates to. Here’s a suggestion. It’s when the sleep deprivation, loss of energy and feelings of hopelessness become an unshakable part of who you are and no longer just an externally imposed irritation that can be handled.

1. James F. Paulson and Sharnail D. Bazemore
Prenatal and Postpartum Depression in Fathers and Its Association With Maternal Depression: A Meta-analysis, JAMA
2010; 303(19):1961-1969

2. Sarah L. Halligan, Lynne Murray, Carla Martins, Peter J. Cooper
Maternal depression and psychiatric outcomes in adolescent offspring: A 13-year longitudinal study. Journal of Affective Disorders 2007; 97(1): 145-154

3. Susan Pawlby, Dale F. Hay, Deborah Sharp, Cerith S. Waters, Veronica O’Keane Antenatal depression predicts depression in adolescent offspring: prospective longitudinal community-based study.
Journal of Affective Disorders 2009; 113(3) 236-243

4. P. Ramchandani, A. Stein, J. Evans, TG O’Connor and the ALSPAC study team
Paternal depression in the postnatal period and child development: a prospective population study
The Lancet 2005; 365: 2201-2205

5. Anita Thapar, Stephan Collishaw, Robert Potter, and Ajay K Thapar
Managing and preventing depression in adolescents
BMJ 2010; 340: c209.

Kirsten Patrick is an assistant editor at the BMJ.
Conflict of interest: Kirsten Patrick used to work as a researcher in perinatal mental health, has experienced the post partum period firsthand twice, and has a recurring nightmare about having to experience it a third time.

A very intereting article Edward and yes congratualations on becoming a parent. As a health care worker for many years within both mental health and health visiting I find myself agreeing with the points made. Ante natal and postnatal care is essentially a femal dominated environment these days, and in many areas preparation for parenthood is rather elusive and not available ubiquitously throughout the UK – shame!