In early 2019, the American Academy of Pediatrics (AAP) released a policy statement1 recognizing that “maternal depression affects the whole family” and urging pediatric providers to “incorporate recognition and management of perinatal depression into pediatric practice.” Soon after, the US Preventive Services Task Force issued new recommendations on interventions to prevent perinatal depression.2 The convergence of these 2 statements from nationally recognized bodies of experts in evidence-based medicine underscores the urgency of a heightened focus on screening and making referrals for perinatal depression in pediatric practice.
The new recommendations do not go far enough and risk being out of touch with contemporary American families. The US Preventive Services Task Force evidence review and recommendations are focused exclusively on interventions to prevent maternal depression. The AAP statement acknowledged paternal postpartum depression (PPD) as an established clinical problem yet called for pediatricians to screen solely mothers at the 1-, 2-, 4-, and 6-month well-child visits and “consider screening the partner as well” at the 6-month visit. We believe it is inadequate to treat the recognition and management of paternal depression as extra or optional. To promote optimal outcomes for children, pediatric providers must assess the mental health and adjustment to parenting of all new parents, regardless of gender or marital status, and make appropriate referrals for needed care.
Fathers’ time spent with children has nearly tripled since 19653 ; even among unmarried couples, fathers typically want to be and are involved with their children.4 Evidence has accrued over the last 2 decades demonstrating the many ways that fathers contribute to their children’s health, including the association of paternal PPD with adverse child outcomes.5 One major issue is that a clear set of diagnostic criteria that is specific to paternal PPD does not exist. Nevertheless, paternal depression occurring within the first postpartum year is generally considered to be PPD. Across studies, prevalence ranges from 2% to 25%.1 Fathers who are younger, of lower socioeconomic status, or have a history of depression are at greater risk.6
Paternal PPD impacts parenting and family functioning and has short- and long-term implications for children’s health. It is associated with reduced parenting engagement, warmth, and sensitivity; increased couple conflict; and child psychopathology.4 By the end of the child’s first year, fathers with depression are more likely than fathers without depression to report spanking their children and are less likely to report reading to their children.7 Paternal PPD is associated with poorer child emotional and behavioral outcomes in childhood and adolescence.5
Research on paternal PPD is limited, and additional research is needed, in particular to deepen understanding of depression among fathers of diverse backgrounds and family circumstances. Existing research demonstrates notable variation between the onset and presentation of paternal PPD and maternal PPD. Paternal PPD tends to develop more gradually, with longitudinal studies suggesting that the rate of paternal depression decreases in the period shortly after childbirth then increases over the first postpartum year5 ; additional findings report as much as a 68% increase in depressive symptoms in the 5 years after entrance into fatherhood compared with nonfathers.8 Although some symptoms are common across maternal and paternal PPD (eg, depressed mood or loss of interest in activities), mothers are more likely to report sadness, and fathers are more likely to present with increased irritability and alcohol and substance use.5 Maternal and paternal PPD are highly correlated; combined, the effect on children is compounded.1 Research demonstrates the substantial societal costs of untreated maternal perinatal mental health issues and points toward the cost-effectiveness of early interventions9 ; comparable cost-benefit analysis is needed to understand the economic burden of paternal PPD and the value of effective treatment.
Recognition and Management of Paternal PPD in Pediatrics
Paternal PPD has been associated with many poor outcomes in children and families, warranting a timely response from pediatric providers. The following is a set of evidence-informed recommendations to reduce barriers to identification and treatment and to prevent adverse outcomes of paternal PPD.
Fathers are less likely than mothers to seek help for depression.1 Lack of awareness of paternal PPD presents a remediable barrier to fathers seeking treatment. Knowledge about PPD has been shown to facilitate help seeking by mothers, and education regarding paternal PPD may lead to increased help seeking by fathers.10 Through anticipatory guidance, pediatric providers can help all new parents recognize the possibility of depression in themselves and their partners, recognize the tangible effects of depression on parenting, and know when to seek (or encourage a partner to seek) help.
Screening With Appropriate Assessment Tools
Opportunities to screen fathers in pediatrics exist; the vast majority of new fathers attend at least some well-child visits, including a large majority of fathers with depression.7 However, a universally accepted and well-validated diagnostic tool for screening for paternal PPD is lacking. This absence is representative of the larger problem of insufficient research on paternal PPD. Because there is currently no specific paternal PPD screening tool, paternal PPD has typically been assessed by using screening instruments and cutoff scores developed for mothers and adjusted for fathers. These adjustments may not be sensitive to the distinct presentation of depression in new fathers. For example, somaticizing symptoms and externalizing behaviors are not measured in the most frequently used scales for assessing maternal PPD.
Efforts are underway to develop a screening tool specifically for paternal PPD.11 In the meantime, we can learn from those who have already adopted screening for fathers at well-child visits despite the barriers. Pediatric providers can screen fathers using the Edinburgh Postnatal Depression Scale, a well-validated and widely used screening measure for mothers that has been validated for fathers with minor adjustments in cutoff scores,12 or the 2-item Patient Health Questionnaire, a quick and valid screener for all adults. In addition, pediatric providers can use observations across multiple encounters during the infant’s first year of life to recognize behavior change, identify the possibility of depression, and make appropriate referrals.
Referral for Treatment
Both early identification and intervention are critical. Reducing paternal depression symptoms will increase the capacity for emotionally sensitive and responsive parenting, make it less likely that a father and his infant will experience attachment problems, and support new parents’ relationships. Although there is still much to learn about how best to engage fathers and treat paternal PPD, existing evidence suggests the benefits of pharmacologic or psychological therapies.13 If paternal depression is resulting in impaired parenting, fathers can also be referred for support to build parenting skills.14 Pediatric providers may need to locate new referral resources to respond to these needs.
A Comprehensive Approach
The Council on Patient Safety in Women’s Health Care has developed an evidence-based maternal mental health safety bundle that presents actionable best practices for perinatal mental health education, screening, intervention, referral, and follow-up across varied care settings.15 This bundle offers a model for the development of protocols for identifying and responding to paternal mental health issues in pediatric practice. Practices that currently use depression screeners on previsit questionnaires for infant well-child visits are already identifying some fathers with symptoms of depression. It is now critical to recognize paternal depression as a community of pediatric providers and ensure consistent screening, referral, and follow-up.
Screening All New Parents for Depression
With the most recent AAP clinical report on the role of fathers in children’s health and development documenting advances in the understanding of paternal depression and its effects on child outcomes and recognizing the importance of identifying fathers at risk,16 it is time for the focus on perinatal depression within pediatrics to include fathers. This is not to diminish the urgency of early identification and response to maternal depression. As described in the AAP policy statement,1 untreated maternal depression poses significant risk to the infant, dyad, and family. Screening new mothers and fathers for depression is responsive to ample and growing evidence that PPD on the part of any parent, regardless of gender or marital status, poses risk to child well-being. As a trusted and accessible resource to new parents, pediatric providers are uniquely positioned to conduct PPD screening and make needed referrals. Serving the whole family with effective interventions is the best way to support the well-being of children and is consistent with a family-centered care approach.
Dr Walsh conceptualized the perspective piece and drafted the initial manuscript; Drs Davis and Garfield conceptualized the perspective piece; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
American Academy of Pediatrics
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.