Sunday, September 18, 2016

Post-natal depression - not just about mothers

Photo by Steven Van Loy @mafalou from unsplash.com
Post-natal depression in dads?
When I started writing this, I thought I was going to write about one thing: men feeling extreme and sometimes debilitating sadness, irritability and/or worthlessness after the birth of a child. I thought I was going to write about how sceptical host Mike Hosking looked in the Seven Sharp piece on television about post-natal depression in men, and I would write about how real it actually is.

On second review of that television piece, though, I was spectacularly unimpressed. I forgave Mike his scepticism for two reasons: firstly, I think he accepts that big life changes can make people feel bad – but it requires real disruption and self-examination of the kind that many working dads don’t go through because, despite a lot of social change, dads’ lives are still less disrupted than mums’ lives. Perhaps he was sceptical because he didn't face the kind of upheaval others do.

Secondly, the story implied that post-natal depression in women and men is caused by hormonal changes, which arouses my suspicions. Too often we reach for biological explanations for human suffering, and I think paternal post-natal depression is almost so self-explanatory that it defies a need for biological explanation.

A lot of fathers have a really hard time after the birth of a child and I don't think there's a need for me to attempt to prove that. However, aware that there is a lot of misinformation and rumour around, I reviewed some websites, some recent research and some news stories and found a few things I think it’s important to talk about: what is post-natal depression; how is it different in men; what factors make it more likely to happen and is there evidence that it is caused by hormone changes; and does it need to be treated? My answers are below, but first, my overall impression.

The societies I have lived in and the cultures in which I became a father are not well-equipped to deal with a problem like this. Fathers can experience powerful and difficult emotions while feeling isolated, worthless when they can’t find their place in the new relationship and responsibilities structure, and overwhelmed with responsibility when they can. They may not have anyone to talk to about it even if they can overcome the expectation that they solve it themselves. We still tend to socialise boys in a way that suppresses or denies emotion rather than acknowledging it, and I suspect this is at the heart of the condition discussed here, and it is liberation from this socialisation that is at the heart of treating it: there is almost universal acknowledgement that troubled fathers need to talk more and be heard.

I was told many times over that I needed to provide support for my wife as a new mother but seldom advised to ensure that I had the same – and I got the impression that there is competition for rare sympathetic resources that should really be unlimited: the needs of the mother deserve no less attention when we pay attention to her partner. After reading more about paternal post-natal depression, I urge readers to give more support to dads. Ask how they are and listen to the answer. Share your stories - being a parent is hard work and we need to hear more about the rough side of being a dad. In addition, I'm struck that for all my concern about the lack of information about the paternal version of post-natal depression, it's blatantly obvious that  partners of mothers who are not fathers are even more ignored. At the bottom of this piece I invite your stories, and I would encourage everyone who can relate to this as the partner of a mother to respond.

1. What is post-natal depression (PND)?
One of the striking differences about this particular phenomenon is that the trigger of the emotions is identified in the name of the condition. You don’t get ‘post-spousal death depression’ etc. and I wonder if people more readily accept a diagnosis like this when it includes a specific reference to an understandable cause. My first step was to look at formal diagnosis. The American Psychiatric Association produce a Diagnostic and Statistical Manual that is now in its 5th major edition, which, although eternally controversial, contains up-to-date psychiatric thinking on symptoms for a very big range of conditions. In the latest edition, for example, a bereavement exclusion was removed from the diagnosis of major depression. Previously, it was not recommended to diagnosis depression in a person suffering from grief for up to two months after the death of a loved one. Some viewed this as a move to further medicalise human experience and encourage the unnecessary prescription of medication, and others viewed it as more liberating. It was not until the previous major edition of the DSM that post-partum was introduced as a specifier, in a sense establishing it as a type of depression. Now it is possible to diagnose major depression with peripartum (i.e. around the time of giving birth, not just after) onset, and up to 4 weeks after birth. So the basic story is that depression following childbirth is not considered different in terms of symptoms, but giving birth is recognised as a specific trigger. After 4 weeks, though, it’s regular major depression. None of that seems to have any bearing on the situation in New Zealand and in the UK, though, where any number of websites alert parents to the problems of PND and PPND (the paternal version) and dispense advice and warnings. Estimates in my quick sampling of websites dealing with the topic range from 10 to 20% of women and 3 to 10% of fathers to 26% at the peak time for this condition at 3-6 months after delivery.

2. What does PPND look like?
This is clearly a tough question because most of the available information available is about mothers. Some information is rather weak – inviting any reader to panic instantly as Babycenter.com defines PPD as, well… having a baby:

a woman with PPD may be:
sleep-deprived
transitioning to motherhood and dealing with the psychological adjustment
hormonally unsteady
breastfeeding or weaning
experiencing worrisome thoughts about her baby or her ability to be a good mother

consumed with guilt and disappointment about what's supposed to be the "best time of her life."

Some of the New Zealand websites are better. The Ministry of Health offers a sometimes gender-neutral set of symptoms:

always feel tired
cry a lot
feel that you are a bad mother
have aches and pains
think bad thoughts
do not sleep well, even when your baby is asleep
feel that you can’t cope with anything, such as housework
feel anxious or uncertain all of the time
don’t care about how you or things around you look
get angry with other people around you, such as your partner, other children or your whānau.


Four sites I looked at, the Mental Health Foundation, Plunket, the Health Promotion Agency’s depression site and Kiwi Families, don’t mention that men or partners can suffer from it, and there is only passing mention at The Postnatal Distress Centre. It takes quite some time before I get to a specific explanation of what the paternal version looks like. Parents.com’s Sad Dads post mentions some specifics, including irritability, anxiety, feelings of worthlessness, and engaging in risky behaviour, particularly related to alcohol and other drugs, gambling, or infidelity. And then there’s losing your sense of humour and being miserable a lot of the time. Everything is much clearer after I find an expert on the topic: Lloyd Philpott. With an already substantial body of work on PPND, he offers most of the answers I’m seeking and this guide for primary healthcare professionals is, in contrast to everything else I’ve seen, remarkably clear and focused. Two additions to the list of male symptoms worth noting here are excessive self-criticism and increased escapist behaviours, such as television watching and work. In sum, it seems like a lot of common addictive and risky behaviour tendencies are exacerbated with the arrival of a new baby and a possible deterioration in their relationship with the mother. The importance of PPND is also clarified: it is a major health risk for men, and may have long-term impact on relationships in the family, with knock-on effects for the child’s development.

Note: after writing this post, I found a champion website that somehow nailed it. Look at Well Women Franklin for good info. Not only do they recognise the male form of PND, they do their best to describe it and provide links to the limited services available.

3. What factors predict the occurrence of PPND?
Although a history of depression is frequently identified as a very important predictor, for women, being single or unemployed at the time of birth, and bottle-feeding are identified as increasing risk in an Irish study. A meta-analysis considering more than 80 studies adds self esteem, social support, infant temperament and socioeconomic status to the list along with the pregnancy being unplanned – but note that these are all predictors, not necessarily causes. Such social and psychosocial factors, along with personality, have been found to be more important than any birth complications in predicting symptoms at 8 weeks after delivery in an Australian study. Likewise, the Growing Up in New Zealand study has yielded some important results, and is one of few studies explicitly attempting to address the problem for men: the key predictors for fathers are stress and relationship troubles. If relationship troubles seem to be so important, you have to wonder to what extent it makes sense to look at post-natal depression as an individual phenomenon; perhaps it’s more sensible to look at it as a feature of the transition to parenthood (the title of a book by Jay Belsky) experienced by several people together, as seen in this more dynamic model that looks at the partnership as both a possible cause of distress and a possible target for improvement.

4. What about hormones?
The theme of hormone change is certainly quite prevalent through the various websites I’ve been looking at. At parents.com there are unreferenced claims that women’s PPD is triggered by hormonal fluctuations and unnamed ‘studies show’ that men’s hormones also shift, with testosterone and prolactin levels going down and cortisol going up. The same page also mentions that it is probably no coincidence that the typical onset of PPND at 3-6 months after birth is around the time that maternity leave typically ends and women return to work, and that the current generation of fathers might be experiencing more PPPD as they are more likely to be involved in household tasks than previously. With such a weight of evidence that psychosocial factors are the key to understanding this, is there a need to talk about hormones at all?

Another site, run by psychologist Christina Hibbert, claims that hormones are one of the causes, specifying decreasing testosterone and increasing estrogen as the culprits, with a reference to a USA Today article in which Dr William Courtenay says that men’s hormone levels change and that testosterone changes are linked to depression in men. Curiously, there is no direct link mentioned between these two ideas: Courtenay did not say that reduced testosterone has been found in PPND dads. He has referred interested readers to a study by Kim and Swain (2007) for a discussion of hormones, but those authors explicitly conjecture that there might be a relationship that needs to be tested. Their suggestion is based on a study of older men with depressed mood and low testosterone and studies that suggest testosterone levels decrease in men after the birth of a child with the effect of making them more sensitive and attached fathers. They also suggest that maybe increased estrogen has a role because more involved dads have been found to have higher levels of estrogen (even among rats), but offers no link to depression. They go on to speculate about four other possible hormonal explanations. However, I did not find any evidence of a link, even among articles that have cited it.

The California Psychologist published a piece by Daniel Singley, PhD, which cites the same references for the same purposes but explicitly states no clear link has been found. It does refer to another study mentioned by Courtenay – by Ramchandani et al. (2005), which apparently offered early evidence for a link. I tried and tried, but I can’t find any reference to hormones at all in that paper.

So the rather underwhelming conclusion I have to make is that everything I’ve read about hormones as a cause of paternal post-natal depression is simply conjecture or bad referencing. At worst, it’s an idea that’s made up. Why would a hormonal explanation for male depression be necessary? That’s a question for another time.

5. Does it need to treated? Does it go away?
By now I’m a fan of the ‘family’ approach to understanding PPD. So as I look through treatment advice, that’s on my mind. So advice like this:
Depression isn’t something a guy can simply “get over.” It’s a health condition that needs to be treated – just like a bad heart or injured knee.
just doesn’t sound right. Fair enough, without treatment, it can last for months or years. And it’s true one place to start is your GP or the Plunket nurse. But remember the Plunket website didn’t address men or partners. Lots of sites suggest you should talk to someone as soon as possible. The Father and Child Trust, featured in the Seven Sharp piece mentioned above goes a step further by running drop-in groups and offering telephone numbers without focusing on ‘treatment’. Christina Hibbert’s site is quite helpful with a number of options but the focus on men disappears in this section. Aside from this, there seems to be almost universal agreement that the interventions necessary for men are intimately bound with the likely cause. This article by Anna Whyte in the BOP Times appears to be the most informative and least judgmental and I recommend it.

Collecting stories of PPND
You don’t need to have been diagnosed or treated. Do the emotions mentioned above sound familiar to you? If so, please send an email to editor@hashtagpsychology.com with a brief version of your story if you are willing to feature anonymously in a bank of stories that will help better inform our understanding of paternal feelings after the birth of a child.


Notes

Post-natal is a more generally used term. Because it refers to birth it could be used in reference to the baby, the mother, or anyone around. Postpartum specifically refers to after giving birth and as such tends to be narrowly focused towards the mother. In practice, they are used interchangeably.

If you are seeking advice or support, please use the following contacts as supplied by the Mental Health Foundation:

  • Depression helpline. freephone 0800 111 757 
  • Healthline: 0800 611 116. (Available 24 hours, 7 days a week and free to callers throughout New Zealand, including from a mobile phone).
  • Lifeline 0800 543 35
  • Samaritans – 0800 726 666 (for callers from the Lower North Island, Christchurch and West Coast) or 04 473 9739 (for callers from all other regions)


This article was written by Alan Law for Hashtagpsychology.com

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