Paternal perinatal mental health: evidence review

5. Characteristics affecting experiences of paternal perinatal mental health

As noted, the impact that becoming a father can have on men’s mental health can stem from how men experience childbirth and the myriad of changes in lifestyles, relationships, hormones that often accompany becoming a parent. Some men also develop specific mental health needs relating to depression and anxiety during the perinatal period. It is also the case that factors relating to men’s backgrounds and personal circumstances can influence their mental health during the perinatal period.

However, there is currently limited evidence on how the mental health of men with different characteristics, including those in different equality groups, are impacted during the perinatal period. Although there were studies that described equality group characteristics included in this review, the impact of equalities characteristics was frequently not discussed in the findings. Age and income are the most commonly discussed characteristics within the literature reviewed.

This section considers how age, socio-economic disadvantage, ethnicity, pre-existing mental health conditions and experiences of trauma and separation/divorce can influence paternal perinatal mental health.

5.1. Age

There is mixed evidence concerning the influence of the age of fathers on paternal mental health during the perinatal period. A meta-analysis on 74 studies reporting paternal depression between first trimester and one-year postpartum from 1980 to 2015 found that depression prevalence was not conditional on the father’s age. However, it was suggested that the lack of significant findings could be due to the limited data available on different groups (Cameron et al., 2016).

Other evidence suggest that fathers who are younger may be at higher risk of mental health conditions. A population-based study with expectant fathers identified four PPD profiles including ‘not depressed’, ‘anxious-worried’, ‘depressed’ and ‘anhedonic’ (the loss of ability to feel pleasure). Those in the ‘anxious-worried’ depression profile were more likely to be younger, compared to those in the ‘not depressed’ profile (Garthus-Niegel et al., 2020).

A quantitative study by Bergström (2013) investigated depressive symptoms in men 3-months after their first baby was born. Use of the Edinburgh Postpartum Depression Scale, a questionnaire originally designed to screen women for symptoms of emotional distress during pregnancy and the postnatal period, revealed that fathers aged 28 years and younger had more than a twofold increased risk of depressive symptoms three months after the birth compared with men aged 29–33 years, while men aged 34 years and older had no significant increased risk. Young age being a risk factor for depressive symptoms remained even after considering sociodemographic characteristics such as employment and income and other risk factors, such as partner’s depression and low satisfaction in the partner relationship.

Contrastingly, Carlberg, Edhborg and Lindberg (2018) used the Edinburgh Postnatal Depression Scale and the Gotland Male Depression Scale - which includes symptoms of depressive disorders including those commonly experienced by men, such as anxiety, anger, irritability and antisocial behaviour (Sigurdsson et al., 2015) - to study fathers three to six months after their child was born and found no associations between depression and the fathers age.

Other evidence shows that older fathers may be at risk of experiencing mental health conditions during the perinatal period. A quantitative study investigating the prevalence of depressed mood in first-time fathers reported that older age of fathers was more associated with depressive symptoms at two months postpartum (Da Costa et al., 2019). A cross-sectional study by Nilsen et al (2013) with 14,832 men in Norway revealed that men aged over 35 when their first child was born were more likely to have experienced previous depressive symptoms, one of the risk factors for PPD, compared to those younger than 35 years. Older fathers were also more likely to have sleeping problems than other age groups. However, psychological distress was not associated with more advanced age.

Studies investigating experiences of childbirth also indicate that older fathers have more negative experiences than younger fathers, such as feeling more fearful (Schytt & Bergstrom, 2014; Eriksson et al., 2005). These negative experiences may be explained by the fact that, in most cases, the partners of older men were also of older maternal age, meaning an increased risk of complications and interventions during labour and birth. A study by Stramrood et al. (2013) reported that higher paternal age was associated with more symptoms of PTSD and depression among partners of women with pregnancy complications.

5.2. Socio-economic disadvantage

Research on paternal perinatal mental health has focused mostly on fathers from high-income families (Baldwin et al., 2018). However, low income can be a predictor of both PPD and PPA. In Carlberg, Edhborg and Lindberg’s (2018) study that sought to assess prevalence and risk factors for PDD three to six months after birth, both the Edinburgh Postnatal Depression Scale and Gotland Male Depression Scale indicated that the proportion of fathers with PPD was higher among those in areas with generally lower income.

Similar findings were reported by Da Costa (2017) where fathers of lower household income scored higher on the Edinburgh Depression Scale during the third trimester. Low household income has been associated with an increased risk for depressive symptoms in men three months after their first baby was born, with similar effects on fathers in all age groups (Bergström, 2013). Likewise, a longitudinal study identified low household income as a predictor of postpartum depression in fathers (Leung et al., 2017).

Financial worry and financial stress have also been associated with a higher risk of depression for fathers during the perinatal period (Bergström, 2013; Da Costa et al., 2019; Wang et al., 2021). A study by Henshaw et al. (2023), which investigated depressive and anxiety symptoms in mothers and their partners during a two-day post-partum stay in a hospital, found a significant negative relationship between income and partner anxiety, suggesting that lower income was associated with more anxiety in partners.

Job security stemming from a high-earning profession is positively associated with better mental health in the perinatal period (Cooklin et al., 2015). Conversely, unemployment has been shown to increase the risk of depression symptoms in men during the perinatal period (Underwood et al., 2017; Wang et al., 2021; Da Costa et al., 2017). Contextual factors including the status of fathers' employment, job quality (including workplace conditions, such as control of workload and working hours, job security and access to paid family leave) and occupational prestige were the strongest predictors of psychological distress observed in a quantitative study of 3,219 fathers with children 0 -12 months (Giallo et al., 2013). These associations remained after accounting for other risk factors including parental age, socioeconomic status, stressful life events, child temperament and sleep problems.

5.3. Ethnicity

There was an underrepresentation of minority ethnic groups within the literature included in this review. Most studies from the UK which collected data on ethnicity lacked ethnic diversity (Baldwin et al., 2018). A UK qualitative study with men from various ethnic backgrounds (e.g. Black African, Spanish, and White British) observed that some participants cited difficulties admitting experiencing mental health concerns because these were seen to be less culturally and socially acceptable due to stigma around mental health (Baldwin et al., 2019). A systematic review of studies looking at psychosocial factors associated with PPD in the US reported that fathers who self-identified as African American or Hispanic and who had frequent daily experiences with racism had an increased risk of depression during the perinatal period (Recto & Champion, 2020).

5.4. Pre-existing experiences of trauma and mental ill health

Difficult and traumatic experiences, such as parental substance abuse, domestic violence, separation and divorce, parental imprisonment, and having been a looked after child can negatively influence the mental health of fathers during the perinatal period (Dayton et al., 2020; Schuppan et al., 2019). Perinatal depression in fathers has been found to be associated with a having history of depression (Areias et al., 1996). Several studies also highlight that the level of neuroticism (the degree to which a person experiences the world as distressing, threatening, and unsafe) in fathers is related to their mood and rates of distress in the perinatal period (Matthey et al., 2000; Wong et al., 2016).

5.5. Separated/divorced fathers

Available research indicates that mental health may differ by marital status. For example, research suggest that depression is higher in persons who are separated or divorced (Beach et al., 2003; Whisman, 2007). Evidence shows that being separated or divorced can also be an important factor in fathers experiencing mental health difficulties. A widely cited quantitative study of depression among fathers of infants based on data from the Fragile Families and Child Wellbeing Study, which included a sample of 5000 families in the US, found that separated or divorced fathers reported a higher prevalence of depression compared to cohabiting fathers (Bronte-Tinkew et a., 2007). This finding is reflected in a range of studies (Pinto et al., 2019; Chhabra et al., 2020; Chen et al., 2023).