Abstract
Perinatal depression is prevalent in primary care in the United Kingdom. The recent NHS agenda implemented specialist perinatal mental health services to improve women’s access to evidence-based care. Although there is ample research on maternal perinatal depression, paternal perinatal depression remains overlooked. Fatherhood can have a positive long-term protective impact on men’s health. However, a proportion of fathers also experience perinatal depression which often correlates with maternal depression. Research reports that paternal perinatal depression is a highly prevalent public health concern. As there are no current specific guidelines for screening for paternal perinatal depression, it is often unrecognized, misdiagnosed, or untreated in primary care. This is concerning as research reports a positive correlation between paternal perinatal depression with maternal perinatal depression and overall family well-being. This study illustrates the successful recognition and treatment of a paternal perinatal depression case in a primary care service. The client was a 22-year-old White male living with a partner who was 6 months pregnant. He attended primary care with symptoms consistent with paternal perinatal depression as indicated by his interview and specified clinical measures. The client attended 12 sessions of cognitive behavioral therapy, conducted weekly over a period of 4 months. At the end of treatment, he no longer portrayed symptoms of depression. This was maintained at 3-month follow-up. This study highlights the importance of screening for paternal perinatal depression in primary care. It could benefit clinicians and researchers who may wish to better recognize and treat this clinical presentation.
Background
According to the World Health Organization (WHO; 2021), depression is a leading cause of disability and a major contributor to the global disease burden. It is estimated that over 280 million people in the world have depression. Depression has been estimated at a prevalence of one in eight for men compared with one in five for women (Mental Health Foundation, 2023). Pregnancy and parenthood have been cited as major contributors to male depression. At its worst, depression can lead to suicide. It is estimated that 700,000 people globally die due to suicide every year (WHO, 2021). Research also reports that 3 times more men than women die by suicide. In the United Kingdom, the Office for National Statistics (2022), suicide accounted for 75% of male mortality.
While maternal mental health is well researched, paternal mental health is not (Hanley & Williams, 2017). Perinatal depression (PRD) is the collective term for prenatal (before birth) depression and postpartum (after birth) depression (Wilson, 2017). Perinatal depression is a significant problem around the world and often occurs with co-morbid problems such as anxiety. It can have a significant impact on families (Chhabra & McDermott, 2022). Research reports that paternal perinatal depression (PPRD) can range from 2% to 50%. It is fairly common where maternal perinatal depression (MPRD) is present (Walsh et al., 2020). Research also reports that first-time fathers in their early twenties have a higher risk of PPRD than other males (Bergström, 2013). Globally, depression seems to be reported at a higher frequency in women than in men (Kuehner, 2017). The evidence suggests that the variation in these figures could be linked to the likelihood of some men underreporting their symptoms (Fisher, 2016). This further suggests that reported statistics may be an underestimation of the true prevalence of male depression and PPRD. Risk factors for developing PPRD include new demands and responsibilities, a history of depression and relationship changes (Chhabra & McDermott, 2022; Scarff, 2019). From a biopsychosocial perspective, these sex differences in depression have also been shown at a neurobiological level with differences in prefrontal cortex circuits between male and female depression (Kong et al., 2013). From a social perspective, men have also been shown to externalize their symptoms with anger being the main manifestation. Women tend to internalize their symptoms, for example, sadness (Macdonald et al., 2020). Some authors have suggested that this is related to socially determined values around masculine and feminine norms as well as stigma in male depression. This could also partly explain why men report their depression or seek help at a lesser frequency than women (Oliffe et al., 2016; Staiger et al., 2020). These biopsychosocial differences in male and female depression symptomology and presentation have diagnostic and treatment implications in primary care. Male depression also presents a multitude of symptoms which makes it less recognizable than female depression (Rice et al., 2022). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) defines depression “with perinatal onset” as a major depressive disorder (MDD) during pregnancy or within 4 weeks after parturition. This is characterized by five or more symptoms over 2 weeks. At least one of these symptoms is depressed mood or loss of interest or pleasure. Although these criteria are used for both women and men, there are subtle differences. Symptoms of perinatal depression in men resemble those in women with added anger, irritability, or interpersonal conflict (O’Brien et al., 2017). These additional symptoms can lead to misdiagnosis. Obtaining additional information around anger and interpersonal changes and assessing for past episodes and correlation to pregnancy can further aid the recognition, diagnosis, and treatment of PPRD (Scarff, 2019).
Key barriers to the recognition of PPRD in primary care include lack of clear diagnostic criteria and poor screening tools (Walsh et al., 2020). For example, the routinely used DSM-5 (APA, 2013) manual and Edinburgh Postnatal Depression Scale (EPDS) checklist (Cox et al., 1987) both endorse the female symptomology and do not delineate the gender differences in MDD. This led some authors to suggest the need to screen both mothers and fathers during pregnancy (Edward et al., 2014). Other authors also emphasized a person-centric approach to recognizing depression in men (e.g., McDermott et al., 2022). More recently, the updated Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR; American Psychiatric Association, 2022) has endorsed the gender differences in MDD. They highlight that women experience symptoms related to sleep, appetite disturbance and interpersonal sensitivity, while men are more likely to report reduced impulse control (e.g., anger outbursts) and maladaptive coping (e.g., reduced problem solving and substance misuse). As pointed out by Rice et al. (2022), this new guidance is likely to improve the recognition of PPRD in primary care. In the United Kingdom, only mothers are routinely screened for PRD. There has been an increased recognition of the need to screen fathers too (Walsh et al., 2020). For example, the National Health Service (NHS) England (2018) announced that new and expectant fathers will be offered mental health assessments and treatment under radical action to support families. The National institute for health and care Excellence (NICE, 2020) guidelines also acknowledge the need to tackle inequalities in perinatal mental health service provision.
Why Was This Study Necessitated?
As mentioned above, PPRD is a highly prevalent and significant public health concern (Paulson & Bazemore, 2010). Despite the above mentioned barriers, PPRD still remains overlooked within primary care clinical practice and research. Maternal perinatal depression has been prioritized in the NHS. For example, it was at the top of the NHS England (2019) long-term plan for mental health service growth. To date, there is still insufficient metanalysis research evidence to justify prioritizing PPRD in its own right in primary care. This means that there are no specific screening guidelines for PPRD. This presents challenges for clinicians to recognize and treat men presenting to primary care with PPRD.
This case report presents evidence on the successful recognition and treatment of PPRD in primary care. It could shed some light for primary clinicians who may need some clarity on the recognition and treatment of PPRD.
Case Presentation
The Case
The client was a 22-year-old White British male. He was expecting his first child with his partner of 2 years, who was 6 months pregnant. He was referred to the primary care mental health service by his general practitioner with a diagnosis of MDD, with no suicidal ideation. The client was prescribed 20-mg of citalopram.
Presenting Problem
At assessment, the client’s description of his main problem was consistent with PPRD. He reported low mood, lack of motivation, procrastination, self-critical thought processes, and hopelessness. He also reported anger/irritability and interpersonal conflict. The client was also seeing a support worker for anger/irritability management and communication training. He reported that the problems were impacting on work, social, and private activities.
Measures
The client’s symptoms were measured as follows: Depression symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) scale (Kroenke et al., 2001). Anxiety symptoms were assessed using the Generalized Anxiety Disorder Assessment-7 (GAD-7) scale (Spitzer et al., 2006). Functional impairment was assessed using the Work and Social Adjustment Scale (WSAS; Mundt et al., 2002). The EPDS checklist was used to further screen for PRD. Qualitative information on the treatment was gathered using a patient experience questionnaire (PEQ). Outcomes were measured throughout treatment from start to finish, and at 3-month follow-up. Written informed consent for the publication of this case report was obtained from the client.
Assessment
A cognitive behavioral therapy (CBT) assessment was conducted with the client to develop a shared understanding of his problems. Suicidal risk was assessed to ensure his safety. The clients history of depression was assessed including status prior to the pregnancy. The assessment included suitability for CBT including recognition of unhelpful cognitive and behavioral precipitating factors, and engagement issues. At assessment, the client reported a history of depression in adolescence following parental separation. He reported that the current onset correlated with his partner’s pregnancy and MPRD. The client scored severely on the PHQ-9 and moderately on the GAD-7. He met the diagnostic criteria for MDD in line with DSM-5 (APA, 2013). The client’s goals were to manage his low moods, anger/irritability, and self-critical thoughts as well as build motivation to engage with activity in preparation for the baby.
Case Formulation
The problem was formulated using Beck’s longitudinal formulation adapted for PRD (Beck et al., 1979; Milgrom et al., 1999). As shown in Figure 1, this comprised four parts: The presenting problem; vulnerability factors (history of depression and parental separation); precipitating factors (partner’s pregnancy and presence of MPRD); and maintenance cycles (thoughts, feelings, and behaviors). In line with Beck’s cognitive model, the client reported distorted beliefs about himself (e.g., “I am useless”), the world (e.g., “nobody understands”), and the future (e.g., “it will not get better”). He reported developing rules around shutting down/escaping to avoid conflict. This was then maintained in his day-to-day activities where he isolated himself, for example, by sitting in his room alone playing computer games. These behaviors reinforced his beliefs around being useless, leading to self-critical thoughts, low moods and anger/irritability. This further led to procrastination and avoidance of socializing and going to work (Figure 1).
Developmental Conceptualization of the Client’s Perinatal Depression
Treatment
The NICE (2020) guidelines recommend CBT for the treatment of perinatal depression. The client was offered 12 face-to-face sessions of CBT. These were conducted weekly over a period of 4 months plus a 3-month follow-up session. Treatment was conducted by an accredited CBT therapist supervised by two accredited senior CBT therapists. In line with the client’s problem formulation (Figure 1), the key component of his treatment was behavioral experiments to help him test the validity of his depression-induced maladaptive unhelpful beliefs (Bennett-Levy et al., 2004). The initial phase of treatment consisted of assessment and engagement (Sessions 1–3). This involved a CBT patient interview and use of diagnostic measures to obtain a shared understanding of the client’s main presenting problem. It also comprised of normalization and psychoeducation around the client’s symptoms. The client’s motivation for change and goals were also evaluated. The middle phase of treatment used cognitive restructuring to help the client identify, challenge, and reframe his depression-induced irrational thoughts (Sessions 4–5). This was followed by behavioral experiments to help the client reevaluate his underlying maladaptive beliefs and assumptions and test out new adaptive alternatives (Sessions 6–9). For example, the client conducted a hypothesis testing behavioral experiment to test out the truthfulness of his belief that he was useless. The planned experiment targeted his lack of activity and sense of not contributing. His target cognition was “my moods will not lift if I engage in activity.” His belief rating in this belief was (80% with 0% = no belief and 100% = complete belief). The alternative belief was “it might help if I try” (20%). He tested this by attending an activity workshop with his support worker and rated his associated moods and mastery. Following the behavioral experiment, the client re-rated his original test belief as 10% and his alternative belief as 90%. This was then used as positive reinforcement to plan further behavioral experiments. The final stage of treatment consolidated the client’s learning through behavior change strategies (e.g., graded activity scheduling), skills training (e.g., assertive communication), and planning a blueprint (Sessions 10–12). A 3-month follow-up session was also conducted to review the client’s long-term therapeutic gains.
Outcome
At the pretreatment assessment, the client presented with clinical PPRD. By the end of treatment, he showed reliable improvement as indicated across all measures and his interview. The client reported lifted moods and significant reduction in maladaptive cognitions and behavior. The client had also returned to work. These changes were maintained at 3-month follow-up (Table 1).
Client Symptoms of Depression Symptoms, Anxiety, and Work and Social Adjustment
Note. PHQ = Patient Health Questionnaire-9; GAD = Generalized Anxiety Disorder Assessment-7; EPDS = Edinburgh Postnatal Depression Scale; WSAS = Work and Social Adjustment Scale.
As indicated on his PEQ, the client reported that treatment provided a clear understanding of his PPRD linked thoughts, feelings, and behaviors. He stated that this provided him with the confidence to reframe his self-critical thoughts, set realistic expectations and improve his communication.
Discussion
Being able to recognize and effectively treat PPRD continues to be a challenge in primary care. This is often perpetuated by clinicians not being able to identify the indicators or not having the appropriate guidelines. The clients may not be able to clearly articulate their own symptomology. This can lead to misdiagnosis or untreated problems. In this case, the client’s anger difficulties were initially being emphasized over his depression symptoms. Through interview, collaboration, and diagnosis, his PPRD was recognized. His symptoms were characterized by depression around the pressures of first-time fatherhood. This is reflected in a systematic review on first-time fathers’ experiences (Baldwin et al., 2018), which identified the following triggers including formation of the fatherhood identity and competing challenges.
In this case, there, were no clear service guidelines on recognizing and managing PPRD. As suggested by Scarff (2019), the PHQ-9 aided symptom recognition. The use of the interview to assess for increased irritability, symptoms in the perinatal period, and past depressive episodes assisted diagnosis. Despite the scarcity of randomized controlled trials (RCTs) evaluating treatment of PPRD, research supports the use of individual CBT a first-line psychotherapy option (Scarff, 2019). In the current case, since the symptoms for PPRD constitute those of MDD, the treatment plan was effectively adapted from the NICE (2020) guidelines. This adaptive implementation of existing protocols and the use of CBT assessment and intervention assisted the holistic understanding of the client’s symptoms and treatment. This was crucial for this client as the initial emphasis was on his anger and the need for anger-management. Upon recognizing his PPRD, he was able to get the appropriate intervention which alleviated his symptoms including his anger/irritability.
Limitations of This Study
As with all case studies, the current data lacks external validity and therefore cannot be generalized to other situations. The study was guided by DSM-5 (APA, 2013)—derived measures and interviews, which essentially comprised of female symptomology. Although PPRD was recognized, this may not transpire in other situations. The client also had input from a support worker for anger-management. As this study was not a controlled study, it is not falsifiable and cannot claim cause-effect. The chances of natural recovery, response to medication or anger-management support cannot be ruled out.
Implications for Clinical Practice Future Research
This case illustrates the effective recognition and treatment of PPRD in primary care despite the aforementioned challenges. It also highlights the importance of screening for PPRD in primary care. This case may benefit clinicians wishing to recognize and treat PPRD in primary care.
This case report also highlights areas for further research. For example, anger was highlighted as a key symptom in this case. Research could be conducted to further elucidate the qualitative nuance of this PPRD-induced anger. With the introduction of DSM-5-TR (APA, 2013), future research could design measures to improve the recognition of PPRD in primary care. Future RCTs could also be conducted to understand the distribution and individual differences in PPRD symptoms. The presented case was a first-time father in his early 20s. This has been shown to be a risk-factor in PPRD. Future research could evaluate the age-related correlates of PPRD. Use of RCTs could also help quantify the recognition and cause-effect treatment outcomes of PPRD in primary care.
Footnotes
Acknowledgements
The authors acknowledge the support and encouragement of Daniela Antonie (clinical lead) and Monton Jienpetivate (associate clinical director) of primary care psychological therapies, East London NHS Foundation Trust. The authors also thank the participant for his consent.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics Approval
Ethical approval was sought from the East London Foundation Trust board of Ethics Committee, GECSE (study approval number G2001). Client consent and data management were conducted in line with their recommendations.
Informed Consent
Written informed consent for the publication of this case report was obtained from the client.
