In this issue of Pediatrics, Garfield et al1 present new findings on depression symptoms among mothers and fathers who are parents of preterm infants during the NICU stay and the 30 days after discharge from the hospital. The data reveal that when preterm infants are hospitalized in the NICU, mothers are initially more depressed than fathers (higher scores on Edinburgh Postpartum Depression Scale), but maternal scores have decreased 30 days after discharge in contrast to paternal scores.1 With this study, the authors contribute to a growing literature on the importance of paternal postpartum depression better referred to as paternal perinatal affective disorder (PPAD),2 which encompasses both pre- and postnatal anxiety and depression. Whereas maternal postpartum depression (PPD) is increasingly recognized, PPAD is underscreened, underdiagnosed, and undertreated despite a prevalence of 8% to 20% in some surveys.2–4 Moreover, data suggest PPAD has adverse effects on mothers, their children, and the parental relationship.4,5 Risk factors include adverse childhood experiences,6 previous history of affective disorder, comorbid maternal PPD, unemployment, and low socioeconomic status, among others.4,5 PPAD peaks at 6 months postpartum, continues through 12 months postpartum, and may approach prevalence rates of 20% when preterm infants are less than 32 weeks' gestational age and 40% when nonresident fathers are included in surveys.7
Our improved understanding of the impact of safe, stable, nurturing relationships in buffering toxic stress makes the management of PPAD critically important for pediatricians. Recent studies of paternal grief8 highlight the presence of a term called “toxic masculinity,”9 whereby fathers are less likely to report sadness and weepiness and more likely to discourage breastfeeding and to demonstrate externalizing symptoms such as anger, irritability, substance use, and domestic violence.2 Although the Edinburgh Postpartum Depression Scale used in this study has been validated for fathers as well as for mothers, researchers are studying alternate screens that may better capture the symptoms with which fathers present. The Gotland scale is one such screen that attempts to capture the broader range of paternal symptoms of PPAD.10,11
The authors of this study highlight some of the limitations of the generalizability of their findings. The population studied was predominantly a high socioeconomic status college educated population with almost no nonresident fathers. Furthermore, few of the infants were less than 32 weeks' gestational age and there are no data on illness severity among the infants. Despite these limits, this article emphasizes the need for pediatricians to engage fathers more actively in care. Here are 4 ways to accomplish this goal:
(1) Identify parents, fathers as well as mothers, in the NICU who have risk factors and provide supportive interventions and close follow-up after discharge. (2) Screen fathers at the 4-month well visit for PPAD because mothers are already screened for PPD; monitoring and screening fathers for depression can be continued through the 12-month well visit. (3) Advocate to include fathers in current proposals for paid postpartum family leave. (4) Advocate for the development of a workforce with expertise in parental mental health that acknowledges the presence and need for treatment of men with PPAD. Although we have begun to close the gap for maternal PPD,12,13 a chasm of underrecognized and undertreated depressed fathers must be addressed if we are to support families with young children.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-042747.
POTENTIAL CONFLICT OF INTEREST: The author has no conflict of interest to disclose.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.