•Many mothers grapple with mental health challenges after the birth of a child. But fathers experience PND, too – and may be slipping through the cracks.
•Most men are not given the tools, resources or recognition they need to cope with the transition.
For David Levine, the watershed moment came when he imagined he had shaken his baby.
It was 2013, and his son was two weeks old. He had put him down on a mat "maybe slightly rougher than I should have", says Levine today. At the time, unable to think straight, he was convinced he'd done worse. As a paediatrician, he knew shaking a baby could cause brain injury, even death. He was horrified.
Levine's anger and frustration had been building since his son's birth. Like many newborns, the baby took time to adjust to the outside world. But to Levine, it seemed like he cried constantly. "I took it personally, like I'm failing, I'm not doing my job here," he says. "I also started feeling like it was directed at me – that my son was crying because he did not like me."
Levine loved children. Since he had begun his career as a paediatrician in New Jersey, US, he'd heard one thing over and over from parents: "You're going to make such a good father someday." He had been excited when his wife became pregnant and gave birth. When she had challenges with breastfeeding, and he could use his medical background to help incorporate formula, he felt useful.
But then his role shifted. He didn't need to be a physician; he needed to be a father. And when the practical tasks of parenthood – like getting his son to stop crying – proved to be a challenge, he thought it was his fault.
"That's when things started to spiral," he says. He belittled and yelled at his son. He started to see graphic images of committing violence to his child and himself. And he didn't see how things would get better. "I would tell my wife that this was the end of our life," he says. "All I could envision was the cycle of hell that was going to be our lives."
In his practise, he screened mothers for postnatal depression (PND) – a depressive illness that sets in within a year of giving birth (often referred to as ‘postpartum depression’ or ‘PPD’ in the US). It's usually seen as a female condition. Could it exist for fathers, too? If so, Levine hadn't heard of it.
He wasn't alone. PND, a mental-health condition which can include feeling persistently low, apathetic or even suicidal in the first year after birth, is a well-established phenomenon in women – even if it is one that still remains underdiagnosed and undertreated around the world, sometimes with tragic consequences.
What's less well known, even to those in the medical field, is that men can get PND, too.
But many of the resources that can help prevent, diagnose and treat PND – from the screening questionnaires that doctors use, to support networks like parenting groups – have been built for women. Even the symptoms that people commonly associate with PND tend to pertain more to women than men. Add on the stigma men can feel around expressing mental-health challenges, and experts say that we aren't just missing mothers with PND. Millions of depressed fathers also could be falling through the cracks.
"Although there has been rising community awareness about mental illnesses, such as postnatal depression in women, it’s a phenomenon that's much less recognised in men," says Grant Blashki, the lead clinical advisor of Australian mental health organisation Beyond Blue.
Yet it's been estimated that around 10% of fathers are depressed in the first year after birth, a rate twice as high as in the general male population. Some research has indicated that 10% could be too low; in the three- to six-month period after birth, around one in four fathers exhibit symptoms of depression. Many fathers will also get generalised anxiety, OCD and PTSD, says Daniel Singley, a counselling psychologist in San Diego, California who specialises in men's issues.
But relatively few of these men will reach out – or even believe they have a problem to begin with. “In my practise, it’s interesting that – even if your background is highly educated, or a health professional – there are still high levels of stigma about mental health illness amongst men,” says Blashki. “And this can result in denial or poor help-seeking, or a sense that you should just sort it out yourself."
Generally, men tend to eschew medical care more than women. In Canada, for example, researchers have found that around eight in 10 men won't seek medical care until their partner convinces them to go. But it's also largely due to feelings of embarrassment or shame about being a man – especially a father – with depression. "[Men] really, really don't want to seek mental-health help, because it's stigmatised and feminised. And they really, really don't want to do it during the perinatal period," says Singley.
In heterosexual childbearing couples, he continues, the message usually given to a dad is that pregnancy and birth are a woman's realm. Fathers can be excluded from prenatal appointments, classes or even the labour itself. When they are present, they're often told that their only job is to be supportive, no matter what anxieties or fears they, too, may be feeling.
This messaging activates the masculine stereotype of "protect, provide", says Singley, and it overlooks a key element: fathers need to support mothers, but they also need support. As one dad told researchers in a recent UK study, "Looking back, the institutions, family and myself focussed [sic] on how I would support my wife and the emphasis was on me staying strong."
‘We’re supposed to be the rock’
Then, of course, there is the pressure of masculine stereotypes. If fathers are expected to be strong and supportive, who are they if they are depressed?
In the same UK study, another participant said he "felt like a failure, no true man". Another asked: "What sort of man gets depressed after they've had a baby?" Some were even hard on themselves about receiving treatment; one man who was given leave from work because of his mental-health diagnosis said that when this made it difficult to establish a new routine with the baby, it made his depression worse "as I felt like I wasn't just failing with fatherhood, but husbandhood". Others mentioned worrying their partners would leave them.
"There are still many myths prevalent around mental illness as a sign of weakness or something that a man should just be able to sort out himself," agrees Blashki. "These sorts of myths can be amplified by a sense that the man ought to be the strong one during this big time of transition for the mother and baby."
Levine, for his part, didn't open up to his wife about just how bad his PND was until about a year later, when – after speaking to a patient about PPD, who then passed his name on – he was invited to talk about his experience on the Charlie Rose talk show in the US.
"She didn't know that I was depressed. She didn't know that I had certain feelings towards our son. And also, she didn't know that part of the reason I never told her was because I thought that she would think less of me," he says. "Men don't talk about their feelings, right? We're supposed to be the rock for our spouses. I didn't have anybody to talk to about this. And I genuinely felt that if I told her, she would leave me. And my wife is a wonderful person."
The women’s realm
An additional obstacle is that postnatal depression often is associated primarily with women. Consequentially, it is less likely that a man – or the people around him, including medical professionals – recognise PND for what it is.
It is true birthing parents are more likely to get depression in the postnatal period than their partners (one review found an average of around 24% for mothers, compared to 10% for fathers); it’s also the case that part of why some mothers get PND is because of the hormone changes in the brain that happen on giving birth.
The symptoms also tend to be different in men versus women. While the common image of PND might be a mother who is weepy and unable to get out of bed, fathers with PND are more likely to engage in avoidant or escapist behaviours – working longer hours, say, or spending more time on their phone. They are more likely to abuse substances or alcohol, and to be indecisive, irritable or self-critical.
"Sometimes [men] show what we call a 'masked male depressive presentation', that looks a bit different than typically the way we think about depression," says Singley. "There might be a tendency to somaticise", or feel physical symptoms instead of emotional ones, like stomach pains or migraines.
Some people say that fathers aren't experiencing 'true' PND, but rather general depression – a thought process exacerbated by the fact that fathers are more likely to get depressed postnatally if they have had depression before.
While there is some truth to this, it's misleading, says Michael Wells, an associate professor in the Department of Women's and Children's Health at the Karolinska Institute in Stockholm, Sweden, and a researcher of postnatal care and male PND. Fathers are indeed more prone to postnatal depression if they've had depression in the past. But so are mothers. "It's not hormones alone," he says.
Not only that, but recent research has found that fathers' hormones also change, as early as the prenatal period. Fathers' testosterone levels decrease during their partner's pregnancy, for example, while oestrogen increases towards the end of pregnancy. There is some evidence that paternal PND might be related.
Physiological causes aside, both mothers and involved fathers encounter a number of changes after a baby is born: "adjusting to the new baby, changes to the relationship, changes to the couple’s sex life, new responsibilities, coping with the partner’s stress and financial pressures," says Beyond Blue's Blashki.
"More generally it can be a time of reflection on one’s identity, and many men may worry about the responsibility required to look after a baby."
Particular risk factors also can make some fathers more prone to PND. One is their partner's mental health; the risk of the father developing PND is more than five times higher if the mother has it. (And if the father has PND, the mother is more likely to get it too.)
Other risk factors include lack of job stability, the pregnancy being unintended, poor relationship satisfaction, having a lack of information about pregnancy and birth, less social support, sleep deprivation, and having unrealistic expectations of fatherhood.
(Interestingly, while we normally associate PND with new parents, research co-authored by Wells has found that it isn't just first-time fathers who are at risk of PND; many fathers with other children get PND, too.)
But the fact that even someone like Levine – who had a stable job and marriage, no prior history of mental health issues, and plenty of medical knowledge about pregnancy and infants – could fall into PND so hard, and fast, shows it can affect anyone. For his part, Levine believes his PND was exacerbated by not fully comprehending just how tough parenting could be, or what was normal newborn behaviour. He didn't realise that many infants simply wake frequently, or cry a lot. He put the blame on himself.
‘My personality changed’
Much of this sounds familiar to Mark Williams of Fathers Reaching Out, a fathers' support group in the UK, which has since become a lobbying organisation.
When his baby was born in 2004, Williams, who lives in Wales, was self-employed. He expected to be back to work after two weeks. But nothing went as planned. First, his wife's birth was traumatic. "I had a panic attack in the labour ward, and then the doctor said my wife was going to theatre" for an unexpected C-section, he says. While she was there, no-one told him what was happening. He thought his wife and baby were going to die.
From that traumatic incident, Williams was dropped into the challenges of life with a newborn, all while feeling pressure to get back to his work with "no money and a mortgage to pay". His wife had severe postnatal depression herself.
"I started to use alcohol, avoiding situations. My personality changed," he says. He felt angry and aggressive. Once, he punched the sofa so hard, he broke his hand.
He found out about male PND through a chance conversation with someone who went to his gym: both of their wives had PND and, it turned out, both of them were feeling low, too. When Williams looked to see what kinds of groups were out there for fathers, like there were for mothers, he came up empty.
Over the years, he was able to overcome his depression with cognitive behavioural therapy, medication and more support. He also received a diagnosis of ADHD. But he wanted to make sure that if other fathers moved past the stigma of male PND and asked for help, there would be help for them to find. "There was nothing back then. Nobody was really talking about it," he says.
In 2010, he started Fathers Reaching Out, which connected fathers and offered mental health support and advice. (The organisation has since dissolved, becoming a lobbying group instead, due to "a lack of funding", says Williams). He quickly heard not only from fathers, but also their partners. "Mums were saying 'My husband is really struggling, his behaviour has changed since the pregnancy and baby's been born'," he says.
Williams devoted himself not only to supporting other fathers, but also campaigning. He spoke at conferences, worked with academics, wrote a book, founded International Fathers’ Mental Health Day and lobbied the UK government to offer fathers mental health checks if their partner was suffering a mental health condition – which was successful.
Awareness of mental health in general, and male PND in particular, has improved, he says. But not enough. "It's a lot better, but it's still so unrecognised," he says. "There's no mention of fathers in the NICE guidelines", the national recommendations for health and care in England. "The WHO only has information on mums, not on dads. It needs a big national push – or someone like a celebrity to come out and really push this forward."
An additional problem, says Wells, is that because PND has been seen as a female mental-health disorder for so long, the screening tools health professionals use – most commonly a questionnaire a patient might be asked to fill out at an appointment – were made for women. This means doctors are less likely to catch those crucial male manifestations of PND, and diagnose them accordingly.
And even some medical professionals still think PND is a female issue, says researcher Wells. Recently, he says, "I talked to one nurse and asked her, 'Are you screening dads?' She said, 'No, fathers can't get depressed'," he says. "In her mind, it was all hormonal, and it had to do with giving birth. Therefore, dads couldn't get it."
The price of not getting help can be high. Men in Western countries are four times as likely to kill themselves as women (not, of course, because of PND alone). There also is the effect on families. Fathers have a critical role to play in their infants' early development; one study found that if a child's father was depressed in their first year of life, the child was more likely to have more behavioural difficulties and poorer development and wellbeing at four to five years of age, for example.
One solution to helping catch and address PND, say experts, is to include non-birthing parents, and prioritise their mental health in addition to that of mothers, from the get-go. Wells, for example, has found in his research that when fathers receive more support from midwives, nurses, and their partners, they are much less likely to develop depression.
"The non-birth parent is not addressed, often, by the physicians or by the nurses," says Levine. "You start these families off with the idea that the birth parent is the most important one, and the non-birth parent is secondary. And that's not true. My wife did not experience postpartum depression; I did. But my postpartum depression could have triggered postpartum depression or anxiety in her. Or, had she gotten it, there was a 50% chance that I would have gotten it. And nobody's telling anybody these things. Paediatricians, who are the only doctors who usually see both parents at any time, are not screening these families."
Singley adds it’s also important to make clear to fathers that they will need support. That support can look like reaching out to friends who are dads. Or it can look like fathers' groups, where men gather to chat about the challenges of parenthood. As well as happening in communities, these can also be held online, like those run by the US's Postpartum Support International, or the UK support group Pandas.
But this also requires men to open up. Only by talking about mental-health challenges can we destigmatise it, helping ensure that men who need help get it, all say Levine, Singley, Wells and others.
Better parental leave – and a changed workplace culture where dads who take parental leave are applauded, not stigmatised – would also make a difference, they add. Non-birth parents may not be recovering physically from labour, but they, too, need time to adjust.
Paternal leave also can allow fathers to feel more empowered and involved, which can protect against postnatal depression. When Levine's son turned three months old, he took paternity leave.
"Those three and a half weeks of me being home with him made a huge impact on me because I was his sole caregiver, I was responsible for him and I gained confidence in my abilities as a parent," he says. "From having to feed him to get him dressed, take him in the car and meet my wife in the city or drive to my parents or go see a friend for lunch – I started to realise I could do these things. And that made such a big impact on my self-esteem."
Eschewing the ‘Great Lie’
More broadly, people also need to be more honest about parenting, says Levine.
He often tells people about what he calls the “Great Lie”: the idea that you can have it all. You can work full-time, parent full-time and everything will look like it does in the shiny images of perfect nurseries and smiling babies you see on social media. People often think of this in terms of mothers. But it can also be true of men, who may have an additional, gendered pressure to provide for their families financially.
"Then, when it doesn't look the way you thought it was supposed to look, you pathologise it and you say, ‘It must be me. I must be the one who’s screwing this up. Because my whole life I’ve seen people handling it’,” he says. "There shouldn't be a shame in just saying, ‘Yeah, parenting is hard. Parenting is fun. But parenting is hard, especially in the beginning'.”
For Levine, the fear of admitting he was struggling meant it took a few more weeks – and encouragement from his wife – for him to seek help. He spoke to a therapist where he worked. A postnatal depression specialist who understood men could get PND, she'd never been sought out by a male patient before, she told him. He began doing cognitive behavioural therapy. With the aid of a night nurse for the baby, he started sleeping better.
It wasn't all "sunshine and butterflies", though, he adds. When his second child was born four years later, he experienced PND again. But this time, he recognised the symptoms.
Now on the board of an organisation called Postnatal Support International since 2018, where he will be vice chair from July, Levine will be speaking about male PND at this year's convention for the American Academy of Pediatrics. He tells every parent who comes in with a new baby about his experience. His mission is to destigmatise male PND.
He remains acutely aware things could have gone differently. "When I went through this, if I wasn't a paediatrician, if I didn't work where I worked, it's possible that I wouldn't be talking to you right now," he says today. "Because something really terrible might have happened."