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THE RESEARCH QUESTIONS

2.1 REVIEW OF THE LITERATURE In the Philippine setting, several research studies have been made on maternal postpartum depression but often neglect to study the effect of new birth on the fathers. In this study, the researchers attempt to discover how fathers are affected by the birth of a new child. It is based on the concept that fathers and their well-being have an effect on their babies, even to the point that paternal depression is reflected in the babies development.

Postpartum Depression The most common complication after childbirth is postpartum depression which is regarded as a form of clinical depression (Lee, 2004). According to DSM-IV criteria, postpartum depression or PPD is a form of major depressive disorder (MDD) which has been present for at least a period of 2 weeks after giving birth. Its symptoms can include feelings of inadequacy and failure, a sense of hopelessness, exhaustion, emptiness, anxiety or panic, decreased energy and motivation, and a general inability to cope with daily routines (National Health and Medical Research Council, 2000). PPD occurs more in new mothers but recent studies show that it can also happen to new fathers. From 1980-2002, the incidence of paternal postpartum depression has been significantly increasing according to Goodmans (2004) literature review. Recent studies have shown that one in every ten fathers experience depression following the birth of the child (Paulson, 2010). The highest rates of depression among fathers have been reported between 3 months and 6 months postpartum (Paulson, Bazemore 2010). However, the terms used to describe postpartum depression in males has not yet been standardized and remains an unrecognized phenomenon because the emotional life of fathers are often times overlooked.

According to Schumacher (2008) depression is experienced by males following a birth of a child in several ways. As gender roles shift and paternal involvement in children becomes the norm, the experience of having a child requires major adjustments for the men. Fathers often feel overwhelmed, isolated, stigmatized, and frustrated when they have difficulty coping with the said situation. This now results to possible effects in the early lives of their child (Cooper, 2003; Downey, Coyne 1900; Ramchandani, 2003). An increased risk of behavioural and emotional problems in children can be associated with paternal postpartum depression (Ramchandani, Stein, Evans, OConnor 2005).

Tools and Instruments No instrument has been specifically developed to measure paternal postpartum depression. Some instruments that detect PPD, like The Beck Depression Inventory (BDI) and the Center for Epidemiological Studies-Depression scale (CES-D), are not specific to the postnatal period and contains items that are indistinguishable from changes occurring in MDD such as disturbed sleep, loss of libido, fatigue, weight changes and concentration difficulties (Matthey, 2001). The BDI was not recommended for use as a tool to detect PPD because it requires specialized training for it entails a clinical eye (Melrose, 2010). Of the instruments used to assess PPD, only the EPDS is specific to depression during the postpartum period. While originally developed for use with women, the EPDS has also been validated for use with men (Matthey, PAGE 2001). 6 The 10-question EPDS takes about 5 minute to use, requires no specialized knowledge (Dennis, 2004; Downie, 2003; Pope, 2000) thus making it easier for the participants to answer and comprehend. In cases of post-partum depression, the Parental Bonding Questionnaire is best used together with the Edinburgh Postnatal Depression Scale, in order to assess the effect of treatment on both variables: depression and difficulties of the couple to relate to her child (Klier, Muzik 2004). The use of the PBQ allows the clinician to judge the severity of the relationship disorder and even more importantly to evaluate improvement. The Quality of Relationship Inventory was used to assess the perceived availability of social support from specific relationships. Items were also developed to asses two other dimensions of specific relationships: the extent to which the relationship

is perceived as being positive, important and secure and the extent to where the relationship is a source of conflict and ambivalence.

Theories Related To Paternal Postpartum Depression The theoretical framework of the rites of passage stages (Draper, 2002) was developed to better understand fathers' transition to fatherhood from their personal perspective. According to Draper (2002), fathers accomplish the stages of transition in rel ation to their partner's transition to motherhood. For the men in Draper's study, transition to fatherhood began with the news of the pregnancy and progressed as the pregnancy progressed. The fathers began to see themselves differently, as did family PAGE 7 and friends. They saw themselves in a different light, they began thinking about longterm implications and changing their behavior. Fathers did not directly experience the pregnancy, frustrations arose. Feelings of vulnerability, powerlessness, and exclusion were particularly heightened during labor. The fathers expressed feelings of dislocation at the time of birth, and they did not know whether they should stay with their partner or remain with the baby. According to the Bowen Family Systems Theory, family work as a unit and each member profoundly affect each other's thoughts, feelings, and actions that it often seems as if people are living under the same "emotional skin." People solicit each other's attention, approval, and support and react to each other's needs, expectations, and distress. A change in one person's functioning is predictably followed by reciprocal changes in the functioning of others. When depression in either the mother or the father arises, this may affect the functioning of the family as a whole.

Implications and Effects of Paternal Postpartum Depression Depressed or sad mood may be less apparent in men than women (Cochran & Rabinowitz, 2000). It is usually in their social behaviour that changes are apparent. Withdrawal from social situations, indecisiveness, and cynicism are hallmark signs of depression in men (Spector, 2006). Mens affect may present more anxious or angry than sad (Karp, 1996; Winkler, et al., 2005). Paternal postpartum depression manifests

somewhat differently than for women and may include such symptoms as hostility, conflict, and anger, rather than the more broadly recognized sadness or apathy. In addition, men may self-medicate for their depression by drinking alcohol, and they may withdraw or engage in escape activities such as overwork, sports, sex, or gambling PAGE 8 (Veskrna, 2010). New fathers may experience many of the same changes and stresses that new mothers do, such as sleep disruption, relationship conflicts, and financial strain. Because of many conflicts with work, society now expects men to work more at home and help more with the children. The resultant stress may predispose men to a greater risk of depression in the postpartum period than at other times in their lives (Veskrna, 2010). Paternal postpartum depression can have specific and long-lasting negative effects on childrens development if the symptoms remain untreated over a long period of time. Research has shown that depression in fathers in the postnatal period is associated with poorer social and emotional behavioral outcomes in children at age three particularly in boys even when the mother doesnt have PND (Davey, 2006). Stressors or adversities experienced at this time can have significant and enduring effects on child capacities, continuing into adulthood, including an increased risk of psychiatric disorders. There is consistent evidence emerging of an increased risk of difficulties, particularly behavioral problems and subsequently conduct disorders, in the offspring of fathers who experience high levels of depressive symptoms. Depressed mothers and fathers engage in less positive interaction with their children, with a particular reduction in the degree of enrichment interactions, including reading, telling stories, and singing songs. Paternal depression was associated with a lower likelihood of the father playing with the child outside regularly (Paulson, Dauber, &Leiferman, 2006). When new fathers are depressed, the effects on the family can be far-reaching. Fathers with symptoms of depression are twice as likely to have an infant who cries excessively at 2 months of age than fathers who are not depressed (van den Berg, et al., 2009). Depression in fathers during the postpartum period was found to double the risk of behavioral and emotional problems in their children at 3 years of age (Ramchandani, et al., 2005). Further, paternal postpartum depression in fathers was

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also significantly associated with psychiatric disorders in their children at 7 years of age (Ramchandani, et al., 2008). Fathers who are in poor mental health may not be able to provide emotional support to their partners and children. They may not be able to function well at work, compounding the problem by creating financial stress. Resources for helping depressed new fathers are often limited. Marital difficulties and the stress of responding to a new baby can make it difficult for couples to offer desperately needed support to one another. Healthy fathering role models were not present for many fathers in their own childhood. Social support may be inadequate and discussing emotional concerns may not seem acceptable. While postpartum therapy groups and classes are available for mothers, fathers may not feel welcome. Given the association between paternal postpartum depression and later child psychopathology, nurses have compelling reasons to consider ways to help promote mental health (Melrose, 2010).