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Depression is a mood disorder that causes incessantly feelings of discouragement, sadness, social reticence and withdrawal, along with loss of interest. Major depressive disorder is a chronic disease, a heterogenic syndrome with a reported prevalence of 3.2% in men and 5.3% in women⁽¹⁾.

Paternal postpartum depression (PPD) is defined when paternal depression disorder occurs within the first twelve months in the postpartum period^(2,3). PPD cannot differentiate between the nine symptoms considered in the DSM criteria: if the father expresses a depressive mood, a drop of enjoyment, or he expresses excessive guilt and worthlessness or he is incapable to think or to concentrate, or he has obsessive thinking of death or suicidal ideation⁽⁴⁾.

Many etiopathogenic factors are contributing to understanding the increasing prevalence nowadays. It was stipulated that depression is a disease of modernity, of the society’s urbanization, industrialization, artificial intelligence, secularization, consumerism and westernization⁽⁵⁾. 

At first pregnancy, the mother’s age increased to 29 years old in Romania and at 30 years old worldwide⁽⁶⁾, but also the paternal’s age at first pregnancy. Many couples have their first baby after their 40s.

The transition to parenthood can lead to psychological distress in both mothers and fathers, with short- and long-term effects for the family and infants^(7,8). 

Although ignored in men’s case, postpartum depression is always directed towards the mother. Depression can be explained by genetic predisposition, insufficient familial and social support⁽⁹⁾, or by thyroids dysfunction⁽¹⁰⁾. Maternal depression manifestations may be explained by the fact that women experience more specific forms of depression-related illness, including premenstrual dysphoric disorder, postmenopausal depression and anxiety and postpartum depression. These are associated with physiological changes in ovarian hormones and could contribute to the increased prevalence in women⁽¹¹⁾.

In the last decades, it has been shown that fathers experience significant psychological changes during pregnancy and in the postpartum period⁽¹²⁾. Although approximated, the reported incidence of PPD is stated from 4% to 25% of new fathers^(3,12) and from 4.1% to 16% during the the prenatal period⁽¹³⁾. Many studies have shown the importance of an optimal mental health in fathers for optimal child development and healthy marital relationships⁽¹⁴⁾.

In Romania, depression is underreported. This is mainly due to the fact the mental illness is not timely diagnosed and treated. Many people do not want to admit they have problems and wait longer for mental and psychological healthcare.

PPD is briefly described in the literature, not being classified as a part of a syndrome.

Sometimes, humour is used in the interpretation of the problematic relationship.

The general population has a little understanding on PPD. Daily life stressful and emotional events perceptions and adaptation alterations can affect people’s mental health.

Much of the study of parenting has focused on how parents care for their babies and children and on the development of attachment behaviours⁽¹⁵⁾. Also, it has been analyzed how adults become parents, how women become mothers and men become fathers; how parents (mother and father) develop normative psychological adjustment and reorganization that takes place when an adult is either pregnant or anticipating the birth of their child.

The most common psychiatric disorders that occur with postpartum depression are anxiety and obsessive-compulsive disorders.  Some studies have reported that 95% of mothers and 80% of fathers have recurring thoughts about the possibility of harming their children up to the age of 8 months old. Forty-five percent of fathers reported a concern that their babies could suffocate, about 25% had a concern about feeding their babies, and 3% of men reported a concern about losing babies. These findings suggest that a psychiatric disorder makes fathers more vulnerable to other psychiatric disorders⁽¹⁶⁾.

The transition from woman to mother and from man to father is often reported as a stressful experience. The father’s anxiety and depression can also be translated into violent behaviour towards his partner. Thus, 15% of women reported violence from their partner and 69% said that violence was manifested for the first time during pregnancy or postpartum. Paternal postpartum depression is also considered a risk factor for child abuse and infanticide⁽¹²⁾.

A meta-analysis of 28,004 participants has reported pooled prevalence rates of postpartum depression in men of 8% from birth to three months, 26% from three to six months, and 9% from six to twelve months⁽¹⁷⁾.

Recently, it has been reported that 10% of men get depressed during the first trimester of pregnancy of the partner, up to six months after the child’s birth. The percentage increased to 26% between three and six months after the arrival of the baby. In the United States of America, one in four fathers become depressed after giving birth to their own child⁽¹⁸⁾.

Herein we present the risk factors for the occurrence of PPD. Fathers don’t access medical services that ­mothers do. They don’t tend to see their doctor, obstetrician, general practitioner, paediatrician, maternal or child nurse or midwife, where problems are often raised in women. This glimpse of facts may be helpful for doctors who are dealing with fathers expressing abnormal emotions during pregnancy and postnatally, beyond the adaptation of this new period of life.   

Men’s psychological distress during gravidity and after birth has been related to poor relationship satisfaction, financial burden, poor job quality, and maternal psychological distress⁽¹⁹⁾.

Expecting and having an infant are new and unique experiences which may be related to increased distress at this time, such as extreme responsibility, time spent, extreme fatigue, poor partner, witnessing, birth trauma, infant health and feelings of inadequacy as a parent^(19,20). In a large study from 3,219 fathers, 10% of them have reported elevated symptoms of psychological distress⁽¹⁹⁾.

The risk factors for PPD are the following^(14-21): 

• Negative changes in the relationship.

• Lower socioeconomic status (financial problems).

• Mother’s postpartum depression.

• Personal or family history of depression.

• Unwanted pregnancy.

• Sleep deprivation or chronic lack of sleep.

• Chronic illness or prematurity affecting the child development.

• Difficulty in dealing with your child.

• Lack of a male model.

• Lack of financial, social and psychological help from family or friends.

• He feels excluded and jealous about the mother-child connection.

• Lack of attention from the partner.

• Self-efficacy⁽²⁵⁾. 

Similar to the hormonal adaptation of women to pregnancy and postpartum, there are hormonal changes for paternal adaptation. Increases in estrogen, cortisol, vasopressin and prolactin levels, simultaneously with decreases in testosterone levels are responsible for stronger parent-infant attachment and might be associated with more engaged paternal parenting^(26-28).

In late 1970s, Bandura introduced a new concept of self-efficacy theory for the regulation of emotional states. Briefly, people try only to do what they think they can do. Self-efficacy beliefs make people less stressed, able to regulate emotional stress by reducing their own negative thoughts and by interpreting potentially threatening expectations as feasible⁽²⁹⁾. Men expressing high general self-efficacy beliefs were related to lower levels of depression which is true for the postpartum period⁽³⁰⁾. 
 

New demands and responsibilities in the postpartum period often cause major changes in a father’s life (Figure 1). Fathers often have difficulties developing emotional bonds with infants, compared to women who develop an attachment immediately after birth. The father-child relationship develops more slowly in the first months after birth. Fathers can be jealous of babies because they occupy a large part of their partner’s attention⁽³¹⁾.

An interesting report on 438 couples found that becoming parent at a young age was associated more with potential risk factors for PPD. Symptom’s trajectories were related to family support, but less to friendship support⁽³²⁾. Why our parents didn’t get depressed when we were born?

In conclusion, it remains important for those who are more prone to depression or to other mental disorders to understand when they are at risk. It is important for the general practitioner to carefully decide if fathers’ emotional expression is beyond a normal response to this new period of life. Parenting remains a state of mind.