Today we are continuing with our focus on Dads and we will be reading up on a condition that is just starting to gain recognition – Paternal Postnatal Depression or PPND for those of you who love acronyms.
Dr. Will Courtenay has been working in the field of Men’s Health for quite some time and is internationally recognized for his achievements in his field. According to his bio at Postpartum Men, Dr. Courtenay received his Ph.D. from the University of California at Berkeley and is a Licensed Clinical Social Worker. He is a member of the visiting clinical faculty in the Department of Psychiatry at Harvard Medical School, and has formerly served on the clinical faculty of the University of California, San Francisco, Medical School. Dr. Courtenay also serves as a Coordinator with Postpartum Support International.
In addition to his psychotherapy practice, Dr. Courtenay has spent the last 15 years researching and writing about men’s physical and mental health concerns, and effective strategies for helping men. His work is referenced by researchers throughout the world and has been translated into many languages. Currently, the focus of his research and writing is men’s experiences after the birth of a child – and effective strategies for helping men with postpartum depression.
I am excited to be able to share this interview with you and hope you leave enlightened and open to th very real condition that affects new fathers.
Thank you Dr. Courtenay for your hard work in this area and I also thank you for the time you put into this interview. I know it continue to shed light on a topic that has been in the dark far too long.
What led you to become a Psychotherapist specializing in men’s issues?
Wow! That question takes me back to being a teenager in the late 70s! That was when the Comprehensive Employment and Training Act, or CETA, was enacted. My first social work job was being a CETA worker in San Francisco. I helped teenaged boys – mostly runaways, who were living on the streets of the inner city – to find jobs and housing. After that, I worked in a variety of jobs helping men as a social worker while I continued my education.
After I began my psychotherapy practice, and while I was working on my PhD at the University of California at Berkeley, I became very curious about the silence surrounding men’s issues. No one was talking about them – not doctors, not mental health providers, not the media, and certainly not men themselves. I was shocked to learn, for example, that men were dying nearly eight years younger than women, and yet there was no discussion about it. Most people – including doctors – were not even aware of this fact. And men’s mental health wasn’t any better. Men were killing themselves at rates up to 12 times higher than women were. But again, there was a deafening silence.
So, about 15 years ago, I founded Men’s Health Consulting (www.MensHealth.org). An educational and consulting firm focused on educating health professionals and the public about the health of men and boys, and how to best provide health services to men. That was long before most people had heard of Men’s Health Magazine. Finally, things have changed and men’s health is getting more of the attention it deserves. But now, men’s postpartum depression is where men’s health was 15 years ago – completely in the dark.
The focus of my work as a researcher and social scientist is masculinity. What I discovered is, men’s attitudes about manhood have a direct influence on men’s health and well-being. Take for example, the fact that many men were taught as boys to never cry – and that they were often punished when they did. So, it’s no surprise research shows that men are more likely than women to try to hide their depression – which only worsens the depression. Men are also taught to be tough, self-reliant and never ask for help. This then makes it difficult for men to get the support and professional help they need to recover from depression – and can lead to feelings of shame or embarrassment when they do.
It really pains me to see so many men suffering alone, and in silence. Especially since depression, anxiety and the other emotional problems that affect us are effectively treatable. So, helping men to lead the most fulfilling lives they can – primarily through raising public awareness and through my psychotherapy practice in Berkeley, California – remains a lifelong passion.
When did you first begin to see an increase in men experiencing Paternal Postnatal Depression?
Well – to be honest – what first springs to mind when I hear that question is a really bad analogy: buying a car and suddenly noticing how many of the same cars there are on the road. But the fact is, until you recognize that this problem of postpartum depression in men exists, you don’t see it. Once you know about it, you start to see just how common it is.
The fact is, we don’t know if there actually is “an increase” in Paternal Postnatal Depression (PPND). It’s only relatively recently that the problem has been identified. That doesn’t mean it’s new, it just means we hadn’t identified it before. There probably have always been men who’ve experienced postpartum depression.
Part of what drew my attention to the problem, was becoming a father myself and starting to think more about the experiences of men as fathers. At the same time, I had been watching many of male patients becoming fathers. In fact, it was actually in my clinical practice – working with men who became fathers for the first time – when I first saw men experiencing depression after their babies were born. That’s when I started researching the subject.
What is the occurrence rate for PPND and what are some of the risk factors for developing PPND?
Well, the occurrence rate is surprisingly high. Every day, more than 1,000 men in the United States become depressed after the birth of their children. And according to some studies, that number is as high as 3,000. That’s means that as many as 1 in 4 new dads experience PPND.
The “risk factors” for PPND are basically those things that we believe might cause PPND (see below). Men who are concerned about developing PPND – or concerned about already having PPND – should look over the list of possible causes to see whether they might be at risk.
Would you describe some of the classic symptoms of PPND? What symptoms would warrant a psychiatric emergency?
It’s a great question – and certainly a reasonable one. But it opens a whole can of worms.
“Classic” is probably not the best term to use in this case. PPND is a relatively newly recognized problem. Now that doesn’t mean that fathers haven’t always experienced this problem, it just means we’re only beginning to learn about it. So, because of that, we don’t really know what the “classic symptoms” are. The same is true of men’s depression, in general. What we’ve long thought of as classic symptoms of depression, may have blinded us to the actual symptoms that men experience.
When we think of a depressed person, we usually picture someone who’s sad and crying. But picture instead a guy who’s working 60 hours a week, being a little short-tempered, drinking a couple of martinis at lunch, slipping out of the office to have an affair, and then speeding home to his wife in the evening. Now that’s not who we think of when we think of someone who’s depressed, but these are some of the symptoms of men’s depression – which often looks different than women’s depression. This is part of what makes it easy to overlook men’s depression.
Here are some symptoms of men’s depression or PPND:
§ Increased anger and conflict with others
§ Increased use of alcohol or other drugs
§ Frustration or irritability
§ Violent behavior
§ Losing weight without trying
§ Isolation from family and friends
§ Being easily stressed
§ Impulsiveness and taking risks, like reckless driving and extramarital sex
§ Feeling discouraged
§ Increases in complaints about physical problems
§ Ongoing physical symptoms, like headaches, digestion problems or pain
§ Problems with concentration and motivation
§ Working constantly
§ Frustration or irritability
§ Misuse of prescription medication
§ Increased concerns about productivity and functioning at school or work
§ Experiencing conflict between how you think you should be as a man and how you actually are
A man who’s depressed won’t experience all these symptoms. Some men experience only a few of them, while others experience many. And how bad these symptoms get also varies among men – and over time.
Now, that said, it’s important to point out that men with PPND can also experience “classic” symptoms of depression – such as a sad mood, loss of interest in hobbies or sex, a change in appetite, a sense of worthlessness, poor concentration, and thoughts of suicide. Certainly if a man is thinking about suicide, that would qualify as a psychiatric emergency. We have to remember that men commit suicide anywhere from 4 to 12 times more often than women do. Each day, 75 men in the United States take their own lives. So, any thoughts of suicide in men need to be taken very seriously.
As you can probably tell from this description, PPND is different from the “Daddy Blues” – which many new dads can experience. With normal postpartum stress or the Daddy Blues, a guy’s going to feel better when he gets a little extra sleep, when he goes to the gym, or when he has lunch with a buddy. But with depression, these things won’t make him feel better. With depression, the symptoms are more severe and they last longer. So, if the Daddy Blues last more than two or three weeks, a man’s probably depressed – and he should get help from a mental health professional who specializes in working with men. Left untreated, postpartum depression often worsens.
It’s also important to keep in mind that men are more likely than women to try to hide their depression. And many men are very good at this. In fact, they’re so good at it, they don’t even recognize their depression themselves. So, looking out for any sign of something unusual is critical. The best sign might simply be hearing from his partner, “Honey, you haven’t been yourself lately.”
It’s also important to point out that, even if new fathers don’t have “clinical” symptoms, they can sometimes just feel miserable – and completely alone in their misery. It’s not uncommon for me to hear from men, “I just don’t feel any connection to my baby.” For some men, it’s even harder than this: they can’t stand to be near their baby. They can’t stand the smell of their baby. Or, for other men, they can’t stand to hear their baby cry; just hearing their baby cry makes them completely crazy. And then, on top of that, these men feel horribly guilty for thinking or feeling these things.
What are the causes of men’s Postpartum Depression?
To be frank, we can’t be definitive about the causes of PPND – at least at this point. But, that said, there are a number of factors that research suggest might be possible causes.
It’s likely that sleep deprivation plays a major role in triggering men’s depression. We know that normal, healthy adults who are deprived of good sleep for just one month begin to develop all of the clinical signs of depression. So, sleep deprivation is a very likely cause.
Hormones may also play a role. Everyone knows that pregnant women and breast-feeding mothers go through hormonal changes, but men’s hormones change too. A man’s hormones change both during his partner’s pregnancy and during his baby’s infancy. And it’s a double whammy: not only do our testosterone levels go down, but – at the same time – our estrogen levels go up. Which means less male hormones and more female hormones coursing though our bodies. One man I know got glassy-eyed just learning this; he finally had an explanation why he’d suddenly “broke down in tears” the week before when he saw a squirrel on the street get hit by a car. These hormonal changes can wreak havoc on a man’s life, and may help set the stage for postpartum depression. In fact, there is some evidence linking decreasing testosterone levels with increasing risk of depression in men.
Now, the thing that best predicts whether a man will become depressed is whether his partner is depressed. Half of all men whose partners have postpartum depression are depressed themselves. Part of what I think explains this, is the new father’s loss of his partner to her new job that keeps her occupied 24/7 – and being left on the sidelines while mommy and baby are bonding. We know from lots of research that men have fewer friends and smaller social networks than women do, and that – for many men – their female partners are their primary source of support. The loss of this support – which, of course, is even greater when the mother is depressed – might be a trigger for depression in some men.
Here are some other things that may increase a man’s chances of experiencing PPND are
§ Personal history of depression
§ Relationship stress – with a partner or with in-laws
§ Excessive stress about becoming a parent or father
§ A sick or colicky baby
§ A lack of support from others
§ Economic problems or limited resources
What steps can a man with PPND take to get better and what is the average length of the recovery period?
Well, the good news is that postpartum depression and anxiety are very treatable. Men don’t have to continue suffering. And although these conditions are very serious – and sometimes life-threatening – men can fully recover.
Research shows that the best way to “get better” (or the best treatment) when experiencing depression, is a combination of talk therapy and medication. Now, “talk therapy” can be a scary idea for many men. If that’s the case, then a man should think of it instead as getting some consultation or coaching. The fact is, every man needs a teammate – or a coach – at some time (and sometimes many times) in his life. And if he’s suffering from PPND or depression, that’s one of those times. The important thing is that a man rally with himself to gather the courage necessary to get the help he needs to recover.
It’s also important that he see a psychotherapist who’s trained in working with men. The fact is, we mental health clinicians are human. We’ve grown up with the same stereotypes about men that everyone else has. These stereotypes about how men are supposed to be can often blind clinicians to men’s pain In fact, research shows that trained, mental health clinicians are less likely to correctly diagnosis depression in men than in women. Because of this, and the unique needs men bring to therapy, a man should see someone who has been trained in working specifically with men.
Now, if a man doesn’t get help, it can result in damaging, long-term consequences. Left untreated, we know that postpartum mood disorders often worsen – and they can ruin a man’s marriage or his career, and can lead to serious financial problems. We also know that a father’s PPND has a negative impact on the emotional and behavioral development of his child 3-5 years later.
Suicide, of course, is the most tragic consequence of depression. As I mentioned above, suicide rates are much higher for men than for women. In fact, three U.S. men kill themselves every hour of every day. And men’s depression doesn’t just lead to suicide. Men with depression are twice as likely to die from any cause compared to those men who aren’t depressed. That’s why I call depression “men’s silent killer.”
The truth is, the biggest problem with men’s postpartum depression isn’t the depression itself, but the fact that too many men try to go it alone and don’t get treatment. That’s the worse thing they can do. Men need to recognize that depression is a medical condition – it’s not a weakness of character. For a man to admit he’s depressed isn’t unmanly or admitting defeat; it’s taking charge of his life.
The important thing to remember is that all of the negative consequences of men’s depression are avoidable. With proper treatment and support, men can fully recover from PPND. And if a man can’t do it for himself, he should consider doing for his marriage or the well-being of his child.
Unfortunately, we don’t know how long it takes men to recover from PPND; it’s never been researched. But men should keep in mind that their depression may have been years in the making; it may not disappear overnight. Even a man who recognizes he’s depressed and gets help – by talking to a psychotherapist or consultant right away – can still take a while to recover. If a man starts taking antidepressants, for example, it usually takes the medication 8 to 12 weeks to reach a therapeutic level. The recovery time will also vary depending on what the man’s emotional well-being was like before he became a father.
Now, all of that said, it’s also worth mentioning that – in my experience – men often report at least some relief almost immediately after talking to a mental health professional. That sense of relief often continues until they fully recover from depression.
How can a partner support her husband if he is suffering from PPND?
The number one way a partner can support her husband is by being patient. And the second – and the third – way she can support her husband is by being patient. This is especially true if her husband has already acknowledged that he might need some help.
The fact is, it can take a while for a man to get help – even after he’s decided to do that. And then once he gets help, it can take a while for him to recover. I just heard from a man last week that his wife had been very understanding of his becoming depressed – at first. But when his depression persisted – as it often does, even after beginning treatment – she got impatient. That won’t help a man’s recovery at all.
For the woman who wants to help her husband to get the help he doesn’t know he needs, but she knows he needs, I’d suggest that she look to what’s worked for her in the past. What powers of persuasion has she used that have worked most successfully in the past? What worked when she wanted her partner to do something he didn’t want to do – like cleaning out the garage or mowing the lawn? She should think about these things and what’s worked to influence him in the past. What works is going to be different for every man.
She should also be careful with the words she uses to talk about getting help. She might be comfortable with the notions of “therapy” or “personal growth,” but her partner might not be. It’s a lot safer for her to suggest that he consider some “coaching” or “consultation.” If she’s considering finding some referrals for him, she should try to find someone who’s experienced in working with men.
If both the mother and father are suffering with a Postnatal Mood Issue, what steps should they take together to protect their marriage and the child?
Well, the first thing they should do is to take a deep breath. Then, they should fasten their seat belts and make sure their tray tables are in the upright position.
Now, I don’t want to make light of this most challenging of postpartum situations. But the truth is, it is going to be a very bumpy ride. And, these parents need to be prepared for how bumpy it’s going to get.
Parenthood is hard. Let’s face it; it’s hard for all of us. And, of course, it’s also often filled with pure joy. But, it’s still hard. In fact, three out of four couples say they became dissatisfied with their relationship after their first child was born. That’s because taking care of a new baby is challenging – for most parents. But with postpartum depression it’s different; it’s painfully challenging. And when two parents are depressed, it’s doubly, painfully challenging.
This question is particularly relevant, because we know that half of all women who are depressed have male partners who are also depressed. And – if both parents are depressed – the negative impact on their child’s emotional and behavioral development is even worse than if one parent is depressed.
The truth is, “baby bliss” is something that appears more often in movies and Hallmark cards than in the homes of new parents. Yes, some parents experience what appears to be a seamless transition into parenthood. But I believe that’s the exception. For most parents, it’s more like baby boot camp. (And it’s not the babies who are in training.)
If both mother and father are depressed, professional help is definitely needed – for both of them, individually and as a couple. That means finding an individual psychotherapist for him, one for her, and a couples therapist for both of them. I know it sounds like a lot of talk therapy, but the fact is, that’s the best chance of getting them through this.
Social support for both of them – individually and as a couple – is also going to be important. Involving family can be helpful, but only if the family members involved are supportive of both partners and the relationship. Getting involved in an online forum – like the online forum at www.SadDaddy.com for new fathers – is important. This may be especially true for men, who may be more comfortable getting support in a way that are anonymous.
Probably the best thing couples can to do to protect their marriage – and their child’s development – begins before the baby is even born. Expectant parents should assess both the mother’s and the father’s risk for experiencing postpartum depression (see the question about risk factors). They can go to my web site, www.SadDaddy.com, and check the list of things that can put a man at risk. There are also resources there for new and expectant mothers.
If a man’s at risk for PPND, he should start getting prepared for the possibility that he might become depressed before the baby is born. Building a network of support made up of friends and family – and putting this in place before the birth of his child – is like putting money in the bank. The expectant father can also join a men’s group or a new father’s group.
For men, the best resource is my web site, www.SadDaddy.com. There’s a lot of information, and resources, about men’s postpartum mood disorders, an assessment specifically designed for men to help them determine whether they might be depressed, and an online forum for new dads to talk with one another.
Just as with PPD, is it possible for a father to be ok after one birth and still experience PPND with a subsequent birth?
My guess is, yes. But that’s only a guess; an educated guess. The problem is, we don’t know. We’re only know beginning to understand PPND, and the chance that it can occur after a previously uneventful postpartum experience is unknown.
If you could give an expectant father (new or experienced) just one piece of advice, what would it be?
Have the courage to get help, if you think you might need it. And, if you can’t do it for yourself, do it for your kid’s sake.
And – if I could add a second piece of advice – it would be, be patient with yourself. Parenting is harder than you think. It’s harder than anyone thinks – or anticipates – it will be. It is, as they say, the hardest job you’ll ever have.
And it’s even harder now, when men are expected to be more involved in parenting. Most dads – with their typically can-do approach to things – say, “Sure, of course I’ll be more involved in parenting.” But then they wonder, “What does that mean?”
The fact is, they can’t answer that, because most of these guys had dads who took a completely hands-off approach to parenting. So, that leaves these new dads – who never learned parenting skills from their own dads – uncertain about what to do. Unfortunately, this uncertainty can quickly lead to anxiety – and we know that anxiety postpartum often leads to depression.
Recognizing this – and just how difficult the job of parenting is – will help new dads to cut themselves a little slack. Hopefully, if they can be patient with themselves while they learn this new job, they’ll enjoy being a dad a whole lot more.