Fathers Matter:The Financial, Operational, and Clinical Implications of

Paternal Peripartum Depression

Cassidy Freitas, PhD(c), Marriage and Family Therapist Intern

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # F6a in Period 6October 17, 2015

Faculty Disclosure

The presenters of this session• have NOT had any relevant financial

relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

1. Define Paternal Peripartum Depression

2. Identify action steps utilizing CJ Peek’s Three World View as it pertains to Paternal Peripartum Depression

3. Describe a multi-disciplinary treatment model for Paternal Peripartum Depression

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Defining Terms

• Peripartum Depression

– In accordance with the DSM-V ‘peripartum’ refers to pregnancy and the first year of a child’s life

– Prior to the DSM-V the terms ‘postpartum’ and ‘postnatal’ have been used in the literature

• Specific to the year after a child is born

Paternal Peripartum Depression (PPD)

• PPD can be described as:– A father's marked change in mood, attitude, or

functioning in family/social/or professional roles with onset during pregnancy or in first 1-2 years after a child’s birth or arrival into family.

(definition comes from current Delphi study seeking consensus on the issue)

Significance of the Issue• Parental depression during the peripartum period can have devastating

effects for entire family (Paulson & Bazemore, 2010, 2006, Ramchandani et al., 2011; Wang et al., 2013; Tuszynska-Bogucka, & Nawra, 2014).

• Particularly when untreated (Cuijpers et al., 2015; Habib, 2012; Melrose, 2010)

• Maternal Postpartum Depression– Studied extensively – Approximately 15% of mothers (Pearlstein et al., 2009)

• Paternal Postpartum Depression– Approximately 10% of fathers in the US (Paulson & Bazemore, 2010)

– International prevalence ranging from 5.3 to 31.7% (Dudley et al., 2001; Escriba-Aguir & Artazcoz, 2011; Parfitt & Ayers, 2014).

– One study found 4.7% of postpartum fathers to be at risk for suicide. (Quevedo et al., 2011)

• 20.97% of fathers with postpartum depression were found to be at-risk for suicide (Quevedo et al., 2011)

Significance Continued

– PPD is a real issue

• Biopsychosocial risk factors for PPPD (Escriba-Aguir & Artazcoz, 2011; Huang & Warner, 2005; Kim & Swain, 2007; Letourneau et al., 2012a; Storey et al., 2000; Wee et al., 2001; Yargawa & Leonardi-Bee, 2015).

• Modern father is expected to be more fully engaged in parenting (Bretherton, Lambert, & Golby, 2005; Gage & Kirk, 2002)

• Postpartum men feel their own mental health is minimized by healthcare professionals (Letourneau et al., 2012b)

• Fathers at-risk for going unnoticed and untreated

Symptoms and Trajectory• Symptoms

• low mood• sense of hopelessness • fatigue• feeling inadequate and helpless• changes in appetite/weight • loss of interest in work/hobbies/sex, lack of exercise and regular leisure/recreational activities even when

time is available • feeling overwhelmed, intense anxiety/negative thoughts • irritability/frustration/violence• suicidal thoughts• problems with concentration, lack of motivation• decreased engagement in caregiving activities• escapist behaviors• grief at the loss of their old life and relationship with partner

• Trajectory• May manifest during the 3-6 month postpartum period (Bielawska-Batorowicz & Kossakowska-Petrychka, 2006; Kim &

Swain, 2007; Matthey, et al., 2001; Paulson & Bazemore, 2010)

• Less is known about the trajectory of PPPD during a partner’s pregnancy– Pregnancy has been identified as a period of possible greater stress for fathers (Huang & Warner, 2005;

Condon et al., 2004)

Risk and Protective Factors• Risk Factors

– Maternal depression, – history of mood and/or anxiety disorder, – previous episode during and/or after a pregnancy,– current anxiety or other mental illness, – losses/grief, – increased stress, – biological risk factors, – prolonged sleep deprivation, – poor social support,– birth trauma, unexpected/negative experiences such as special needs baby,– impaired bonding between father and infant, – separation from partner/baby’s mother, marital conflict.

• Protective Factors– Proactively utilizing positive community/social support– Strong relationship with mother/partner– Healthcare professionals who have a greater understanding of paternal depression – Being included in bonding and nurturing experiences– Engaged in effective therapy– Open communication with family and opportunities to talk about openly about feelings– Having other father peers that the father can talk to– Regular exercise– Cultural or other means of having meaning and purpose– Preparation for parental role

Key Stakeholders• Fathers/Mothers/Families• Workplaces• Pediatricians• OBGYN’s• General practioners• Nurses• Midwives• Parent Educators• Mental Health Providers• Social Workers• Early childhood professionals• Federal and State level funders of community health clinics• Associations related to psychology, medicine, and midwifery• Public Health and Social Service groups• Government officials• Insurance companies• Resesarchers• Media

Clinical Considerations• Clinical Considerations

– Scholars suggest screening father’s for PPPD and family-centered interventions when detected (Freitas & Fox, 2015; Habib 2012; Letourneau et al., 2012a)

• Consensus from experts suggests screening at:– 6 months (during pregnancy) – within the first week after birth,– and postpartum at 6 weeks, 3 months, 6 months, 9 months and 1 year

• Yet, there is no guarantee when a father will be present, so it would be worthwhile to assess a father whenever an opportunity presents itself

– Vast majority of physicians do not assess for postpartum depression• Barriers reported: time, patient barriers, lack of knowledge and skills,

follow-up care (Leiferman et al., 2008)

– Medical Family Therapists (McDaniel, Doherty, & Hepworth, 2013). could play important role in addressing these barriers (Freitas & Fox, 2015)

Clinical Considerations

• Assessment tools– Edinburgh Postnatal Depression Screening (EPDS)

tool• Lower threshold cut-off score has been suggested (>9)

– PHQ-2 and 9– Gotland Male Depression Scale– Psychosocial interview to assess for changes in mood,

attitude, satisfaction with family circumstances• Asking, “are you feeling overwhelmed, stressed out,

having a hard time?”

Operational Considerations Continued

• Father involvement in perinatal and postpartum visits• Stepped-care models of care• Mandatory screening of both parents paired with

clear referral sources• Appropriate education and training of medical

professionals and mental health professionals• Childbirth classes that inform families of the issue,

screen, provide resources and make referrals• Available and convenient fatherhood gatherings

** It is integral to the model that Family Therapists build multi-disciplinary collaborative working relationships so that appropriate referrals can be made

Medical Professionals

Screening*

Childbirth Education Peripartum Support Professionals

EDPDS: cut-off > 9

Screen Positive

Screen Positive

Assessment

Medical/ Childbirth/ Peripartum Support

ProfessionalsMedical Family Therapist

(when available)Referral**

Systemic Treatment

Figure I. Multi-Disciplinary Model for Treating PPPD

ScreenNegative

Screen Negative

Screen Negative

Screen Positive

Screen again 3-6 months

postpartum

Screen again 3-6 months

postpartum

Family Therapist

Continuous Collaboration

with Healthcare Team

*Screening should initially take place during partner’s pregnancy

Financial Considerations

• Financial Considerations– Cost of PPPD is unknown– Maternal postpartum depression

• $25,000 a year for one untreated mother and her child in U.S. (Diaz & Chase, 2010)

• Post and Antenatal Depression Association in Australia –Maternal peripartum depression will cost $433

million dollars in 2012 » (Australia population 22.6 million compared to

US population of 320 million)

Financial Considerations

• Potential costs (according to experts):– Untreated mental health issues– Loss of productivity– Hospitalization in extreme cases– Future costs for children– Child abuse (cps involvement, medical costs, foster

care)– Drug and/or alcohol addiction and treatment– Costs/loss of income due to marital conflict and divorce– Health issues

Next Action Steps Needed…• Increasing public and professional awareness• Reducing stigma• Coverage of services by insurance• Convening stakeholders• Developing more appropriate screenings• Lobbying for universal screening• Designing and validating relevant interventions• Treatment networks need to be expanded beyond OBGYNs• Training of healthcare and mental health professionals• Developing education materials to help families know the signs and how to access support and solutions

early• Father inclusion in prenatal and postpartum care• Policy level shifts that put a father’s role as being important in what is commonly called “maternal and child

health”• Robust referral mechanisms• Improving employer awareness• Advocacy for paid paternity leave• Marketing campaigns aimed at increasing father involvement• More research

Bibliography / Reference

1. Bielawska-Batorowicz, E., & Kossakowska-Petrychka, K. (2006). Depressive mood in men after birth of their offspring in relation to a partner’s depression, social support, fathers’ personality and prenatal expectations. Journal of Reproductive and Infant Psychology, 24(1), 21-29.

2. Bretherton, I., Lambert, J. D., & Golby, B. (2005). Involved fathers of preschool children as seen by themselves and their wives: Accounts of attachment, socialization, and companionship. Attachment & Human Development, 7(3), 229-251.

3. Cuijpers, P., Weitz, E., Karyotaki, E., Garber, J., & Andersson, G. (2015). The effects of psychological treatment of maternal depression on children and parental functioning: A meta-analysis. European Child & Adolescent Psychiatry, 24(2), 237-245.

4. Diaz, J. Y., & Chase, R. (2010). The cost of untreated maternal depression. St. Paul, MN: Wilder Research.5. Dudley, M., Roy, K., Kelk, N., & Bernard, D. (2001). Psychological correlates of depression in fathers and mothers in the first postnatal year. Journal Of

Reproductive And Infant Psychology, 19(3), 187-202.6. Freitas, C. J., & Fox, C. A. (2015). Fathers matter: Family therapy’s role in the treatment of paternal peripartum depression. Contemporary Family

Therapy: An International Journal, doi:10.1007/s10591-015-9347-57. Gage, J. D., & Kirk, R. (2002). First-Time Fathers: Perceptions of Preparedness for Fatherhood. CJNR: Canadian Journal Of Nursing Research, 34(4),

15-24.8. Habib, C. (2012). Paternal perinatal depression: An overview and suggestions towards an intervention model. Journal of Family Studies, 18, 4-16.9. Kim, P., Swain, J. E. (2007). Sad dads: Paternal postpartum depression. Psychiatry, 4(2), 35-47.10. Leiferman, J. A., Dauber, S. E., Heisler, K., & Paulson, J. F. (2008). Primary care physicians’ beliefs and practices toward maternal depression. Journal

of Womens Health, 17(7), 1143-115611. Letourneau, N. L., Dennis, C., Benzies, K., Duffett-Leger, L., Stewart, M., Tryphonopoulos, P. D., & ... Watson, W. (2012a). Postpartum depression is a

family affair: Addressing the impact on mothers, fathers, and children. Issues In Mental Health Nursing, 33(7), 445-457.12. Letourneau, N., Tryphonopoulos, P. D., Duffett-Leger, L., Stewart, M., Benzies, K., Dennis, C., & Joschko, J. (2012b). Support interventions needs

and preferences of fathers affected by postpartum depression. Journal of Perinatal and Neonatal Nursing, 26, 69-80.13. McDaniel, S. H., Doherty, W. J., & Hepworth, J. (2013). Medical family therapy: A biopsychosocial approach to families with health problems. New York,

NY: Basic Books.14. Melrose, S. (2010). Paternal postpartum depression: How can nurses begin to help? Contemporary Nurse, 34(2), 199-210.15. Parfitt, Y., & Ayers, S. (2014). Transition to parenthood and mental health in first time parents. Infant Mental Health Journal, 35(3), 263-273.16. Paulson, J., & Bazemore, S. D. (2010). Prenatal and postpartum depression in fathers and its association with maternal depression. Journal of the

American Medical Association, 303(19), 1961-1969.17. Pearlstein, T., Howard, M., Salisbury A., & Zlotnick, C. (2009). Postpartum depression. American Journal of Obstetrics & Gynecology, 200(4), 357-364.18. Ramchandani, P. G., Psychogiou, L., Vlachos, H., Iles, J., Sethna, V., Netsi, E., & Lodder, A. (2011). Paternal depression: An examination of its links with

father, child and family functioning in the postnatal period. Depression And Anxiety, 28(6), 471-477.19. Wee, K. Y., Skouteris, H., Pier, C, Richardson, B., & Milgrom, J. (2011). Correlates of ante- and postnatal depression in fathers: A systematic review.

Journal of Affective Disorders, 130, 358-377.20. Yargawa, J., & Leonardi-Bee, J. (2015). Male involvement and maternal health outcomes: Systematic review and meta-analysis. Journal of

Epidemiology and Community Health, 1-9.21. Tuszynska-Bogucka, W., & Nawra, K. (2014). Paternal postnatal depression – A review. Archives of Psychiatry and Psychotherapy, 2, 61-69.22. Quevedo, L., da Silva, R. A., Coelho, F., Pinheiro, K. A., Horta, B. L., Kapczinski, F., & Pinheiro, R. T. (2011). Risks of suicide and mixed episode in men

in the postpartum period. Journal of Affective Disorders, 132, 243-246.

Learning Assessment

1. Approximately what percent of fathers are at-risk for PPD?

2. Name some protective factors of PPD.3. What is an assessment tool that may help

detect PPD?4. Name some key players in the operational

structure of treating PPD.5. What are some potential financial costs of

PPD?

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!