Why paternal mental health matters too and must be talked about

Samar Hafeez, Consultant Psychologist, India

“Fathering is not something perfect men do, but something that perfects the man.” (Frank Pittman)

Becoming a parent can be one of the most joyous experiences for both men and women. Transitioning into parenthood critically impacts various areas of functioning in both parents. And just like new mothers, new fathers too might have a hard time adjusting to the demands and challenges of the new dynamics.

Taking care of an infant can cause major disruptions in routines. Many new fathers might be unprepared or unsure of their role, which further adds to the pressures of daily challenges.

Moreover, fatherhood brings an array of various responsibilities, expectations and deadlines that require a significant amount of patience, hard work and sacrifice.

A partner’s pregnancy is an overwhelming phase in men’s lives. As they step into a world of the unknown, not having the slightest idea as to what to expect, many new fathers may experience significant amounts of stress, anxiety, helplessness, low self-confidence and loss of motivation, fears, distress around uncertainty, anger and frustration.

Paternal perinatal depression (PPND) is real

As with women, men can experience depression anytime in their lives, which also includes the perinatal period (before or after the baby is born).

Studies have found that the highest risk for depression among expecting fathers occurs in the first trimester.

A growing body of research indicates that the transition into parenthood can put men at a higher risk for developing paternal perinatal anxiety.

Fathers who experience depression and anxiety usually cite stress as a major contributing factor. Sleep deprivation, work-life balance, changes in household routines, physical exhaustion, demanding roles and the inability to take care of themselves exacerbate symptoms of anxiety and depression. Additionally, not knowing how to take care of a child or lacking confidence in one’s abilities to take care of an infant (low parental self-efficacy) can increase first-time fathers’ feelings of helplessness.

What are the causes and risk factors?

A variety of other risk factors can contribute to a father’s susceptibility to perinatal depression, including:

• Personal or family history of depression: Past depressive episodes, as well as prevalence of depressive disorders within family can increase the risk of perinatal paternal depression.
• Hormonal shifts: Low levels of testosterone have been directly linked to depressive symptoms in men.

A decline in the hormone testosterone before and after childbirth can cause paternal perinatal depression.

• Feeling excluded or disconnected: As the family’s focus shifts to mother and baby, many first-time fathers feel left out, lonely, isolated, ignored or even forgotten. Not being able to participate in the mother-baby bonding can also induce depressive symptoms in a dad.
• Partner’s depression: Maternal depression or anxiety episodes can induce or exacerbate already existing symptoms of depression in a new father.
• Relationship turmoil: Marital dissatisfaction, negative criticism, frequent disagreements, emotional pressure, communication difficulties and compatibility problems raise vulnerability.
• Lack of social support, financial and/or workplace strains (both physical and mental): Absence of practical and emotional support and encouragement from family, in addition to workplace stress could be critical triggers.
• Pregnancy or delivery complications: A difficult pregnancy journey and a traumatic birth experience can increase the chances of depression among expecting/new fathers. Furthermore, having to undergo fertility treatments (regardless of whether the cause of infertility is the man or the woman in the relationship) can affect self-esteem and self-confidence in men, thereby adversely affecting their mental health.
• Bereavement/grief: Previous loss of child or death of partner can pose an increased risk of experiencing depression.

What are the signs of paternal depression and anxiety?

Men exhibit symptoms of depression differently to women. They may however exhibit some traditional symptoms including:

• Changes in sleep
• Changes in appetite
• Inability to feel pleasure
• Withdrawal from family/work
• Avoidant behaviours

These can be exhibited along with some less obvious symptoms such as:

• Anger
• Irritability
• Emotional rigidity (difficulty in empathising with another person’s emotions)

And also some somatic symptoms such as:

• Nausea
• Fatigue
• Digestive issues like constipation
• Hyperacidity
• General aches and pains (head, back/joints)

It is important to highlight that suicidal ideation, substance abuse, intimate partner violence and aggression can be expressions of undiagnosed depression.

Anxiety is often associated with women but it is also common in men.

The symptoms to look out for are as follows:

• Persistent and excessive worry related to infants’ and partners’ well-being and/or feelings of inadequacy
• Restlessness, feeling jumpy and keyed up
• Steering away from social life and intimacy, isolating/distancing from partner, family and colleagues largely due to fear of criticism, embarrassment, disapproval and rejection
• Avoidant behaviours such as excessive screen time, excessive work, stress eating and/or substance abuse (nicotine, tobacco, drugs, alcohol) which serve as negative coping mechanisms/distractions to save oneself from the uncomfortable or painful feelings

Adverse effects of untreated paternal perinatal depression and anxiety

A father’s mental health heavily contributes to the overall well-being of the family. It has a profound influence on parent-infant bonding, emotional regulation in a child and long-term partner relationship.

Research shows that children exposed to paternal perinatal depression show psychological and behavioural problems seven years later.

One such disorder was conduct/oppositional defiant disorder: notable uncooperative behaviour towards authority figures such as parents, teachers etc.

Furthermore, perinatal paternal depression was associated with increased risk of depression in the offspring.

Overall, it can result in low marital quality and satisfaction in the long run, along with less paternal warmth and sensitivity.

Asking for help is not a sign of weakness, but a real sign of assertiveness, courage and wisdom

Many fathers suffer in silence, keeping their mental and emotional health struggles to themselves, eventually making it worse. Here are certain measures that should set a path towards prevention, early detection and recovery:

1. Be aware of the symptoms of paternal perinatal depression (PPND): Even though it is similar to maternal depression, the symptoms trend towards anger, irritability, tantrums/outbursts, disconnection from family, friends and spouse and avoidant behaviours.
2. Reach out to family, friends and primary/specialist healthcare professionals: Do not do it alone. Seek help from support networks that offer perinatal psychoeducation and provide psychotherapy and couples therapy (especially when both partners are depressed or if the relationship is suffering).

Normalise discussions around your mental health with an OB/GYN or paediatrician on your next visit. You can also join a dad’s support group to connect with the experiences of many new fathers out there.

3. Acknowledge your feelings and communicate openly: Acknowledge that whatever you might be feeling is true and there is nothing to feel ashamed of.

Talk your feelings out to your spouse, parents or close friends who create a non-judgmental space to engage in difficult emotional conversations. Furthermore, generate open conversations with regards to your partner’s mental health too.

4. Crying does not mean you are weak in faith: Men are usually expected by society to repress their emotions. Why is it astonishing to see a man or a boy cry? Why do we stigmatise or limit a man’s emotional repertoire? It is mistakenly believed that expression of any type of sentimentality in men is not acceptable, or normal even.

It must be understood that crying is a natural human response to pain, sadness and grief, it is an essential emotional outlet that preserves your mental well-being by reducing the burden of unresolved problems.

Feeling vulnerable in front of your God and/or loved ones or even a therapist is not a sign of cowardice. Shedding tears is a normal human response to loss/pain and not something that is contradictory to faith.

The Holy Prophet^sa showed that crying is not weakness but a sign of mercy. For example, once the Holy Prophet^sa cried when his infant son Ibrahim was taking his last breaths. When a companion around him was surprised to see him cry, the Holy Prophet^sa explained: “O Ibn ‘Auf, this is mercy”. The Holy Prophet^sa further explained that, “The eyes are shedding tears and the heart is grieved, and we will not say except what pleases our Lord. O Ibrahim! Indeed, we are grieved by your separation.” (Sahih al-Bukhari, Kitab al-janaa’iz, Hadith 1303)

If the greatest of men could be brought to tears, then surely that should reassure men from all walks of life that there is nothing to be embarrassed about.

5. Embracing positive masculinity (+M): +M accentuates every healthy trait of a masculine identity. It promotes self-awareness, encourages authenticity, responsiveness, empathy, emotional flexibility (ability to consider different perspectives) and constructive emotional expression while rejecting “toxic” traits such as aggression, dominance and unhealthy emotional repression/avoidance.

This can help alleviate negative feelings and behaviours, thereby positively contributing to personal and relational growth.

The world is in dire need of +M as it motivates men to demonstrate pro-social feelings such as compassion, kindness, empathy, nurturing and caring behaviours towards oneself, family and society. The Holy Prophet^sa showed boundless compassion and mercy to all. This is not surprising since the Holy Quran honoured him with the title of mercy to mankind. (Surah al-Anbiya’, Ch.21: V.108)

His understanding of human flaws and acknowledgement of a wide range of emotions that are felt across both genders, surpassed any human on this planet. He felt deeply and empathised and expressed his feelings constructively, which was extremely helpful and always aimed at improvement rather than destruction.

Positive masculinity generates energy and enthusiasm that leads to personal growth and well-being of those around you.

6. Connect with your child: Make a conscious effort to enhance bonding with the baby. Involve yourself in the process of child rearing: feeding, bathing, changing diapers, reading etc. A strong bond that is built through consistent hands-on care, skin-to-skin contact and active engagement lays a foundation that fosters health, security and emotional attachment in the baby. The father’s involvement can result in a child who is emotionally regulated, has stronger vocabulary and social intelligence.
7. Spend quality time with your partner (before and after birth): Accompany your spouse to the doctor’s office whenever you can and attend antenatal classes to learn more about the birthing process and your baby’s developmental milestones.

In addition, always remember you both are still married and marriage always needs work even during the perinatal phase. Spend time over dinners/lunches with your partner whenever possible. Spending time in each other’s company might open up channels and unlock viewpoints and discussions regarding each other’s wishes and expectations around nurturing and parenting, which will help reduce miscommunications and conflicts along the journey.

8. Seek spiritual and community nourishment: Spiritual and religious practices can act as a protective factor against the development and recurrence of depression in high-risk fathers by instilling hope, meaning, purpose, patience, fortitude and clarity of thought and perception.

Community support can improve coping, alleviate symptoms of depression, and may even prevent relapse in high-risk individuals.

The Holy Prophet’s^sa ultimate reliance for help was no doubt on Allah, but he also sought practical help and counsel from companions whenever needed – in accordance with the teachings of the Holy Quran (Surah ash-Shura, Ch.42: V.39) – which indicated that he did not underestimate help-seeking behaviour and did not ignore the assistance that would take his efforts forward.

9. Dads matter – the role of family members: Fathers experiencing perinatal anxiety and depression usually feel unnecessary and invisible which makes them recoil and isolate further.

Family members should listen and validate a new father’s feelings, and should not expect or force him to give more than they actually can. We must make sure to include the father in all the caregiving responsibilities, so that he does not feel lost or neglected.

Create non-judgmental spaces for men to discuss their worries, fears, struggles, expectations and boundaries. If you see a man hurt or dejected, reach out immediately, reassuring him that asking for help is not a sign of vulnerability or loss of masculinity but a great sign of strength and awareness.

10. Self-care is not selfish: A crucial reminder: tending to your mental and physical health is not an option but a necessary part of survival. Nourish your body and mind with positive habits like mindfulness, adequate sleep, balanced diet, sports and exercise. Remember, these habits provide you with the energy and motivation that is needed during the perinatal period.
11. Reduce stigma and taboo, and motivate fathers: Public health education initiatives must be carried out by local government authorities in order to increase awareness, acceptance and quality specialist care around men’s mental wellness.

There is a significant challenge of addressing the higher rates of suicide and low rates of help-seeking behaviours among men.

Developing national policies, events and strategies that focus on prevention and early intervention can help reduce stigma and bring forth a tradition of happiness-filled and conflict-free transition into fatherhood. Furthermore, perinatal screenings of fathers and mothers during provider visits should be mandated.

Conclusion

All great men in history were human beings who experienced setbacks and myriad emotions and failed numerous times before they succeeded. It is alright to feel sadness and grief. The Holy Quran acknowledges such emotions:

“I only complain of my sorrow and my grief to Allah […]” (Surah Yusuf, Ch.12: V.87)

We all should allow ourselves to feel and experience, while maintaining our love, faith and dedication. Let us understand the nature and mechanism of taboos around mental health in our respective environment and work together to extinguish them.

Overall, it is crucial to understand that a family’s well-being depends on the mental health of both partners. Expecting certain things to come naturally can add pressure and unrealistic expectations during this difficult phase of life.

Parenthood is sometimes about trial and error: you learn as you go. Rest assured, if appropriate actions are taken then the constant feelings of inadequacy and insufficiency will eventually fade away; leading you to a flourishing fatherhood experience. Insha-Allah!