Paternal perinatal mental health: evidence review

7. Barriers to men accessing mental health support during the perinatal period

Increased mental health support for men during the perinatal period could be beneficial in helping fathers better understand some of the mental health challenges and needs they can experience and develop when becoming a parent. Understanding barriers to appropriate mental health support for fathers during the perinatal period is important because accessing support during this time may reduce stress and the possible negative impacts on mental health in the longer-term (Mayers et al., 2020).

A further need for supportive services is demonstrated by studies showing that fathers often feel they lack essential knowledge or skills to manage the demands of the perinatal period, which may negatively affect their mental health (Da Costa et al., 2017; Daniels et al., 2020; Darwin et al., 2017; Domoney & Trevillion, 2021; Lever Taylor et al., 2017; Schuppan et al., 2019). Moreover, if men do not receive support with their mental health needs during the perinatal period there is a risk of harmful implications for their partners and children (Sweeney & MacBeth, 2016).

The following section explores barriers identified in the literature to fathers accessing mental health support during the perinatal period. These include a lack of perinatal mental health services for fathers, fathers feeling excluded from perinatal services, a lack of self-awareness about mental health needs among men during the perinatal period, and stigma and gender-based barriers.

7.1. Lack of perinatal mental health services for fathers

A lack of perinatal mental health services for fathers is a key barrier for men experiencing difficulties in the perinatal period. This includes an overall lack of access to effective, evidence-based treatments and other appropriate services (Fisher et al., 2021). In part, this is due to the limited research assessing the effectiveness of treatments or interventions for men with mental health needs during the perinatal period (Goldstein et al., 2020).

While there are more generalised evidence-based treatments for men, such as psychological interventions (e.g. cognitive behaviour therapy) that could address core symptoms and problems that men encounter at other points in the life course, and treatments designed for perinatal women that could be utilised, there are likely other elements relating to the specific transition to fatherhood that need to be accounted for to allow existing treatments and interventions to be adapted. Examples of this could include how fathers’ own experiences of being parented might influence their own parenting identity, how they are preparing for and anticipating change to their social and familial relationships, and the formation of their own personal values stemming from who they want to be as a father (Deave & Johnson, 2008).

A Delphi study^[1] by Domoney et al. (2020) unpacked this further, relating to specifically developing a CBT intervention for PPD. It concluded that support for fathers should be framed around learning about becoming a father rather than depressive symptoms. The study found that approaches should provide information about infant development and the importance of social support and encourage social connections and good physical health.

7.2. Lack of inclusion in perinatal mental health services

As well as a lack of specific services for men, research has reported that existing perinatal mental health services can be un-inclusive towards men or that their mental health is overlooked or ignored by perinatal health professionals. Among the services that are available, few are tailored to the specific needs of fathers and many are less accessible to men for structural reasons, such as appointments only being available during standard business hours (Wells & Sarkadi, 2012; Wynter et al., 2015).

Studies have found that fathers can feel ignored and side-lined by perinatal health professionals (Fletcher et al., 2006; Gervais et al., 2016). Examples of this include: fathers feeling excluded when attending appointments with their partners to address perinatal mental health difficulties; healthcare services and staff not asking or seeking the opinion of fathers or listening to what they have to say; and healthcare professionals being unconcerned about fathers’ mental health or only including them by explaining what a mental health problem means for their partners (Darwin et al., 2017; Hambidge et al., 2021; Lever Taylor et al., 2017; Schuppan et al., 2019).

A meta-synthesis of 23 qualitative studies of fathers’ experiences of maternity care in high income countries found that they felt ‘left out’, like ‘bystanders’ or ‘invisible parents’ (Steen et al., 2012). Fathers have also reported being unaware of where or how to seek mental health support (Darwin et al., 2017). The cumulative consequences of this, as noted by Hambridge et al (2021), is that if fathers do not expect to receive support with their mental health during the perinatal period and are less likely to know it exists or where to look for it, mental health needs may be left unaddressed and could potentially escalate.

7.3. Lower awareness and recognition of mental health needs among men during the perinatal period

In general, men are less likely to recognise possible mental health needs or concerns than women, as well as having typically poorer mental health literacy (Wilhem, 2014). For example, men are less likely to interpret depressive symptoms (such as moodiness and irritability) as signs of mental illness.

Specific to the perinatal period, fathers have been found to be more likely to conceal or not disclose mental health needs or concerns (Wagner et al., 2007; Berger et al., 2013). Qualitative research by Hambidge (2017) found that fathers could be unaware of mental health problems that relate or are attributable to experiences during the perinatal period. This lack of awareness meant fathers questioned the legitimacy of their mental health concerns, a situation compounded by, as noted above, fathers reporting that services did not cater for or had little awareness of the mental health needs of fathers during the perinatal period. Other research also finds that men may be reluctant to express their support needs or seek help amid concerns that doing so would detract from their partner’s needs (Darwin et al., 2017).

7.4. Stigma and gender barriers to fathers seeking mental health support

Masculine stereotypes and normative expectations around fathers’ mental health can be an important barrier to seeking support from services (Domoney et al., 2020; Pedersen et al., 2021). Fathers may be reluctant to seek support for their mental health because they perceive help seeking as stigmatising or because seeking support contradicts their own or other people’s views on masculinity (Rominov et al., 2018, Venning et al., 2021). A qualitative study from Switzerland which described first-time parents’ formal social support needs in the early postpartum period found that mothers’ and fathers’ needs were different, with fathers more often considering their own needs to be less of a priority compared to those of their partner and child (Schobinger et al., 2022). The same study also found that fathers did not want to burden services by asking for support, a finding reported in several other studies (Shorey et al., 2017; Baldwin et al., 2019; Hodgson et al., 2021). This phenomenon can be explained by fathers experiencing an inner conflict between being more involved and not wanting to take the support away from their partners (Darwin, 2017). Some fathers report that asking for support is socially unacceptable (Baldwin, 2019). This highlights some of the traditional and cultural norms of men as fathers and does not necessarily mean that they do not need support. Studies in the neonatal context show that fathers tend to hide their own worries and have difficulties talking about feelings and requesting support (Hugill et al., 2013).

In a qualitative study by Davey et al. (2006), fathers attending a parental support group reported that they felt the need to remain stoic, and not reveal that they were having mental health difficulties as a parent. There was also reluctance and embarrassment among participants to disclose to others that they were attending a men’s support group, despite finding the experience valuable and enjoyable. Related to this is evidence that men are more inclined to minimise symptoms of mental health risk (Galdas et al., 2005) and are often reluctant to disclose mental health symptoms (Farrimond, 2012; Isacco et al., 2016; Oliffe et al., 2016).

There is limited evidence on how stigma and gender barriers may impact men from different equality groups from seeking mental health support. In a UK, qualitative evidence involving fathers from minority ethnic backgrounds found that some participants reported that it was culturally and socially unacceptable to admit experiencing difficulties due to stigma around mental health (Baldwin et al., 2019). Qualitative research about health visitor interactions with fathers noted that some did not feel comfortable engaging with fathers about their mental health for out of fear of causing offence or distress due to individual cultural, religious or personal beliefs (Whitelock, 2016).