Why men struggle in silence?

Many mothers grapple with mental health challenges after the birth of a child. But fathers experience PND, too – and may be slipping through the cracks.

For David Levine, the watershed moment came when he imagined he had shaken his baby.  It was 2013, and his son was two weeks old. He had put him down on a mat "maybe slightly rougher than I should have", says Levine today. At the time, unable to think straight, he was convinced he'd done worse. As a paediatrician, he knew shaking a baby could cause brain injury, even death. He was horrified.

Levine's anger and frustration had been building since his son's birth. Like many newborns, the baby took time to adjust to the outside world. But to Levine, it seemed like he cried constantly. "I took it personally, like I'm failing, I'm not doing my job here," he says. "I also started feeling like it was directed at me – that my son was crying because he did not like me."

Levine loved children. Since he had begun his career as a paediatrician in New Jersey, US, he'd heard one thing over and over from parents: "You're going to make such a good father someday." He had been excited when his wife became pregnant and gave birth. When she had challenges with breastfeeding, and he could use his medical background to help incorporate formula, he felt useful.

But then his role shifted. He didn't need to be a physician; he needed to be a father. And when the practical tasks of parenthood – like getting his son to stop crying – proved to be a challenge, he thought it was his fault. 

"That's when things started to spiral," he says. He belittled and yelled at his son. He started to see graphic images of committing violence to his child and himself. And he didn't see how things would get better. "I would tell my wife that this was the end of our life," he says. "All I could envision was the cycle of hell that was going to be our lives."

In his practise, he screened mothers for postnatal depression (PND) – a depressive illness that sets in within a year of giving birth (often referred to as ‘postpartum depression’ or ‘PPD’ in the US). It's usually seen as a female condition. Could it exist for fathers, too? If so, Levine hadn't heard of it.

He wasn't alone. PND, a mental-health condition which can include feeling persistently low, apathetic or even suicidal in the first year after birth, is a well-established phenomenon in women – even if it is one that still remains underdiagnosed and undertreated around the world, sometimes with tragic consequences.

What's less well known, even to those in the medical field, is that men can get PND, too.  

But many of the resources that can help prevent, diagnose and treat PND – from the screening questionnaires that doctors use, to support networks like parenting groups – have been built for women. Even the symptoms that people commonly associate with PND tend to pertain more to women than men. Add on the stigma men can feel around expressing mental-health challenges, and experts say that we aren't just missing mothers with PND. Millions of depressed fathers also could be falling through the cracks.

Hidden disease

"Although there has been rising community awareness about mental illnesses, such as postnatal depression in women, it’s a phenomenon that's much less recognised in men," says Grant Blashki, the lead clinical advisor of Australian mental health organisation Beyond Blue.

Yet it's been estimated that around 10% of fathers are depressed in the first year after birth, a rate twice as high as in the general male population. Some research has indicated that 10% could be too low; in the three- to six-month period after birth, around one in four fathers exhibit symptoms of depression. Many fathers will also get generalised anxiety, OCD and PTSD, says Daniel Singley, a counselling psychologist in San Diego, California who specialises in men's issues.

But relatively few of these men will reach out – or even believe they have a problem to begin with. “In my practise, it’s interesting that – even if your background is highly educated, or a health professional – there are still high levels of stigma about mental health illness amongst men,” says Blashki. “And this can result in denial or poor help-seeking, or a sense that you should just sort it out yourself."

Generally, men tend to eschew medical care more than women. In Canada, for example, researchers have found that around eight in 10 men won't seek medical care until their partner convinces them to go. But it's also largely due to feelings of embarrassment or shame about being a man – especially a father – with depression. "[Men] really, really don't want to seek mental-health help, because it's stigmatised and feminised. And they really, really don't want to do it during the perinatal period," says Singley.

In heterosexual childbearing couples, he continues, the message usually given to a dad is that pregnancy and birth are a woman's realm. Fathers can be excluded from prenatal appointments, classes or even the labour itself. When they are present, they're often told that their only job is to be supportive, no matter what anxieties or fears they, too, may be feeling. 

This messaging activates the masculine stereotype of "protect, provide", says Singley, and it overlooks a key element: fathers need to support mothers, but they also need support. As one dad told researchers in a recent UK study, "Looking back, the institutions, family and myself focussed [sic] on how I would support my wife and the emphasis was on me staying strong."

‘We’re supposed to be the rock’

Then, of course, there is the pressure of masculine stereotypes. If fathers are expected to be strong and supportive, who are they if they are depressed?  In the same UK study, another participant said he "felt like a failure, no true man". Another asked: "What sort of man gets depressed after they've had a baby?" Some were even hard on themselves about receiving treatment; one man who was given leave from work because of his mental-health diagnosis said that when this made it difficult to establish a new routine with the baby, it made his depression worse "as I felt like I wasn't just failing with fatherhood, but husbandhood". Others mentioned worrying their partners would leave them.

"There are still many myths prevalent around mental illness as a sign of weakness or something that a man should just be able to sort out himself," agrees Blashki. "These sorts of myths can be amplified by a sense that the man ought to be the strong one during this big time of transition for the mother and baby."

Levine, for his part, didn't open up to his wife about just how bad his PND was until about a year later, when – after speaking to a patient about PPD, who then passed his name on – he was invited to talk about his experience on the Charlie Rose talk show in the US.

"She didn't know that I was depressed. She didn't know that I had certain feelings towards our son. And also, she didn't know that part of the reason I never told her was because I thought that she would think less of me," he says. "Men don't talk about their feelings, right? We're supposed to be the rock for our spouses. I didn't have anybody to talk to about this. And I genuinely felt that if I told her, she would leave me. And my wife is a wonderful person."

The women’s realm

An additional obstacle is that postnatal depression often is associated primarily with women. Consequentially, it is less likely that a man – or the people around him, including medical professionals – recognise PND for what it is.

It is true birthing parents are more likely to get depression in the postnatal period than their partners (one review found an average of around 24% for mothers, compared to 10% for fathers); it’s also the case that part of why some mothers get PND is because of the hormone changes in the brain that happen on giving birth. 

The symptoms also tend to be different in men versus women. While the common image of PND might be a mother who is weepy and unable to get out of bed, fathers with PND are more likely to engage in avoidant or escapist behaviours – working longer hours, say, or spending more time on their phone. They are more likely to abuse substances or alcohol, and to be indecisive, irritable or self-critical. 

"Sometimes [men] show what we call a 'masked male depressive presentation', that looks a bit different than typically the way we think about depression," says Singley. "There might be a tendency to somaticise", or feel physical symptoms instead of emotional ones, like stomach pains or migraines.

Some people say that fathers aren't experiencing 'true' PND, but rather general depression – a thought process exacerbated by the fact that fathers are more likely to get depressed postnatally if they have had depression before.

While there is some truth to this, it's misleading, says Michael Wells, an associate professor in the Department of Women's and Children's Health at the Karolinska Institute in Stockholm, Sweden, and a researcher of postnatal care and male PND. Fathers are indeed more prone to postnatal depression if they've had depression in the past. But so are mothers. "It's not hormones alone," he says.

Not only that, but recent research has found that fathers' hormones also change, as early as the prenatal period. Fathers' testosterone levels decrease during their partner's pregnancy, for example, while oestrogen increases towards the end of pregnancy. There is some evidence that paternal PND might be related.

Physiological causes aside, both mothers and involved fathers encounter a number of changes after a baby is born: "adjusting to the new baby, changes to the relationship, changes to the couple’s sex life, new responsibilities, coping with the partner’s stress and financial pressures," says Beyond Blue's Blashki. "More generally it can be a time of reflection on one’s identity, and many men may worry about the responsibility required to look after a baby."