Depressive Symptoms in Expecting Fathers: Is Paternal Perinatal Depression a Valid Concept? A Systematic Review of Evidence

Background. Since the identification of Couvade syndrome in the late 1950s, little attention has been dedicated to the issue of depression in expecting fathers. Objective. To quantify the extent of depression in expecting fathers and find out if they match their pregnant partners’ depression. Methods. We conducted a PubMed and ClinicalTrials.gov search using paternal depression and all its variants as terms. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement to include eligible studies. Results. We identified a grand total of 1443 articles, of which 204 were eligible. The total number of fathers/expecting fathers involved was 849,913. Longitudinal studies represented more than half of the included studies; more than three-quarters of the studies used the Edinburgh Postnatal Depression Scale (EPDS). The average occurrence of paternal depression was around 5%, which confers the entity some clinical dignity. Depression tends to occur more in expecting women and new mothers than in expecting partners or new fathers, while the co-occurrence in the same couple is quite low. Limitations. The methodological heterogeneity of the included studies prevents us from meta-analyzing the obtained data. The validity of the instruments used is another issue. Conclusions. Paternal depression is distinct from maternal depression and occurs at lower rates (about half). The very existence of a paternal depression clinical entity is beyond any doubt. Future research should address methodological heterogeneity.


Introduction
The fact that a woman's pregnancy could affect her husband's mental and physical health has long been known; the English naturalist Robert Plot (1640-1696) observed in 1677 that "In the birth of man it is equally strange, that the pangs of the woman in the exclusion of the child have somtimes affected the Abdomen of the husband, which yet to such as have experimented the secrecy of sympathies, . . . " [1]. The term used was Couvade syndrome, after a Breton word meaning hatching or brooding [2]. These authors defined Couvade syndrome as "as a state in which physical symptoms of various kinds occur in the husbands of pregnant women, and are of psychogenic origin and connected in some way with pregnancy". The syndrome is also called sympathetic pregnancy, emphasizing the empathetic and sympathetic nature between wife and husband, which David Hume (1711-1776) envisaged as sympathy [3].
The pathways leading to the sharing of symptoms and distress during a woman's pregnancy are entangled in the intracouple relationships, which may change during pregnancy and involve increased anxiety and a loss of self-confidence in both members of the couple. For example, one of the two or both may have a sense of inadequacy regarding his/her role as a parent and may thus influence the other, increasing his/her anxiety or helplessness about the new parental role [4]. The pregnancy period is one marked by the continuous and rapid evolution of intracouple dynamics and the resetting of aims and scope in life for each couple member and for the couple as a whole. We may assume that the brain is reoriented towards increased maturation, but sometimes this process is far from complete. Younger and more inexpert parents may act in immature ways and hurt one another's feelings; in this way, depression may result.
The presence of depression in women during the perinatal period is well recognized. It can be of diverse nature, according to how pregnancy interacts with the basic characteristics of the childbearing woman. The depression could be framed within a major or other depressive disorder or develop within the context of a bipolar diathesis, in which case it would need a different approach and treatment. Differently from women's perinatal depression, which has been known since the time of Hippocrates (4th Century BC) [5], depressive reactions in the father were recognised only in the 20th century [6]. However, since the late 1950s, the literature on fathers' depressive reactions during their wives' pregnancies has not kept pace with that on women's perinatal depression (1733 records on PubMed on 13 August 2022 vs. 11,602 results on the same database on the same day). This disparity is regretted by investigators of fathers' perinatal depression, because its consequence is that fewer resources are available for dedicated programs directed to counteracting paternal depression [7,8]. The fact that there are no diagnostic criteria for paternal depression in commonly accepted diagnostic systems [9] renders this disparity a natural consequence.
The presence of depression in a person during the perinatal period could be a factor similar to the synchronization of menses in women living together [10], meaning that it could be easily transmitted to the partner, or the presence of depression could be disjoint in couples, with each member developing his/her own depression during the perinatal period. To respond to this question, we collected all papers providing data on depression in expecting fathers and attempted to compare the presence of depression in men with that in women to see whether they are coordinated. Additionally, we aimed at evaluating the extent to which fathers develop depressive symptoms during their partners' pregnancy by collecting epidemiological data from studies that evaluated depression using adequate assessment tools.
To this end, we carried out thorough PubMed and ClinicalTrials.gov database searches and reviewed each eligible article systematically.

Methods
We carried out a PubMed search with the following strategy: (paternal [ ) AND (delivery OR post-delivery OR predelivery OR prebirth OR postbirth OR postpartum OR prepartum OR pre-partum OR pregnancy OR post-partum OR perinatal OR postnatal OR trimester*) AND (depression OR depressive OR depressed). The resulting documents were searched for eligibility based on the following criteria: experimental studies containing data on fathers' depressive symptoms that were adequately assessed and considered the period from 3 months into their wives' pregnancy to 12 months post-delivery, which had to be normal. Cases of pregnancies considered at risk, stillbirths, where there were no data on depressive symptoms, where there were no data on fathers, no pregnancy, no depression, unrelated to the subject matter, unfocused or inadequate study design, nonhuman (animal) studies, reviews or meta-analyses, opinion papers (editorials, letters to

Results
The searches were conducted on 7 February 2022. The PubMed output was 1439 records and the ClinicalTrials.gov was 4 out of 6 (one was recruiting and another not yet recruiting). The total number of records amounted to 1443. A total of 204 were considered eligible ( Table 1). The search spanned from January /February 1970 to 3 February 2022, while eligible papers ranged from July/August 1983 to 1 February 2022 (actually pub- Figure 1. PRISMA flow diagram of the search strategy, showing the selection process with reasons for exclusion [11].

Results
The searches were conducted on 7 February 2022. The PubMed output was 1439 records and the ClinicalTrials.gov was 4 out of 6 (one was recruiting and another not yet recruiting). The total number of records amounted to 1443. A total of 204 were considered eligible ( Table 1). The search spanned from January/February 1970 to 3 February 2022, while eligible papers ranged from July/August 1983 to 1 February 2022 (actually published in advance in electronic form on 21 October 2021). The per year distribution is shown in Figure 2.  (Table 1).  (Table 1). DI, BCAI LCI. Subjects completed questionnaires within 3 wks of their infant's birth and again 3-5 wks postpartum 3 items on the DI, both prenatally and postnatally, reflecting some degree of disturbance of the fathers were irritability, sleep disturbance, and fatigability. The SMAT resulted in a total sample mean of 124.6, which indicated that the sample was maritally well-adjusted. Prenatal BCAI was 2.57 out of 3.0 compared to 2.1 on the postnatal BCAI. The results of the FAIOF showed subjects reporting a mean of 10.8. In contrast, prospective fathers reported on the FAIOC that they planned to be involved in 12.7 out of 13 of the activities with their infant. In LCI new fathers reported lifestyle changes in an average of 38% of the lifestyle items. Thirty-seven subjects reported not having a sex preference for the expected infant. Of the 16 who did have a preference, 12 preferred a boy and four preferred a girl. Prior to the infant's birth, 36 husbands reported they were equal in importance to the mother, 16 felt less important, and one felt more important. Postnatally, 29 fathers felt equal to the mother, 19 felt less important, and two fathers felt more important in the care of their baby. For 44/53 fathers to be, pregnancies were planned. Expectant fathers reported in the last three weeks of their wife's pregnancy that the method of infant feeding would be totally breastfed (37), partially breastfed (11), and formula fed (5). 3-5 wks after baby's birth, fathers reported that 21 infants were totally breastfed, 10 were partially breastfed, and 19 were formula fed Very few symptoms of depression were noted in the sample, so the correlations between variables, though statistically significant, require further investigation.
Greater age, higher income, more years of education, and good marital adjustment were associated with fewer signs of depression. Fathers who reported more lifestyle changes and greater involvement in baby care also reported more signs of depression especially irritability, sleep disturbance, and fatigability. Age and months married did seem to have an impact on the marital adjustment of the couples. Older fathers seemed to project fewer baby care activities while younger fathers planned to do everything. No significant relationship between The FAIOF and the prenatal or postnatal BCAI suggests that many other factors impact collectively to predict the father's involvement. Unplanned pregnancies (17%) related to greater lifestyle changes At T4 psychological symptoms of anxiety and depression did not change significantly. At T0, 52% of the variance in depression was explained. A T1, 42%, and T2, 45% of the variance in anxiety was explained. At T3, 43%, and T5, 50% of the variance in depression was explained. A consistent predictor of anxiety and depression was parental competence  [14] T0 (5 wks pre delivery) = 192 individuals; T1 (8 wks post-delivery) = 177 individuals Cross-sectional. SSNI, CES-D.
Woman have significantly higher levels of depressive symptomatology at T0. Over time woman's levels of depression decrease at the trend level, whereas men's levels increased slightly. Women also scored higher than men on perceived practical and emotional support and reassurance at each timepoint. Overall, social support did not correlate with depressive symptomatology for either gender at T0, whereas overall support was inversely correlated with ♀ symptoms at T1 but not with ♂ symptoms at T1. Each dimension of support was inversely correlated to depressive symptoms in ♀ at T1, whereas only practical support and reassurance were linked to T1 depressive symptomatology in ♂.
♀ and ♂ did not differ in depressive symptoms at T1. The characterization of depressive mood in the postpartum period as a predominantly "female problem" may constitute a social construction of reality inadequately subjected to empirical testing by means of gender comparison [15] 200 Prevalence of depression: 27.5% in mothers at T0 25.7% in mothers at T1 9.0% in fathers at T0 5.4% in fathers at T1 39 of all participants who scored 13 or more on the EPDS at six months postpartum, and their partners agreed on PAS interview. Comparing the results, the sensitivity of the EPDS, using a cut-off score of 13, was 95.7% for cases of depression in mother and 85.7% in fathers. Specificity, 71% for mothers and 75% in fathers.
The prevalence did not differ significantly in either mothers or fathers from a control group. As expected, mothers had a significantly higher prevalence of psychiatric "caseness" both T0 and T1 than fathers. Fathers were significantly more likely to be cases if their partners were also cases [16]  Prior pregnancy: 46.3% ♀ had at least one episode of depression. 21.4% ♂ ♀ had a significantly greater lifetime history of depression than did the ♂. during pregnancy: the difference was not statistically significant 16.7% ♀ 4.8% ♂ after childbirth: 49.0% ♀ 23.8% ♂ Comparing the ♀ to the ♂ cumulative incidence of depression at the periods 0-3 and 4-12 months after birth, a statistically significant difference was found in the first period, but not in the last Giving birth and being more directly involved in child rearing renders mothers more vulnerable than fathers to depression in the first few months postnatally. postnatal depression in the fathers seems to follow on from the early occurrence of depression in their wives Longitudinal. T0 = ♀ second trimester T1 = 6 mo. Post-delivery. Questionnaire for the perception of work, SSNI, CES-D x CES-D score for ♀ at T0 was 14.9 and 13.6 at T1; for ♂ at T0 was 10.08 and 10 at T1. At T0 and T1 ♀ scores were significantly higher than ♂. At T1 31% of ♀ and 18% of ♂ scores 16 or higher indicating probable depressive symptomatology When ♂ and ♀ were analyzed together, perceptions of low levels of emotional support from partner and low control and social gratification at work and in the parenting, role were significant predictors of higher depressive symptomatology. Perception of boss supportiveness and social gratification at work were more important for ♀ who were working than for ♂ [18] 370 Mothers' mood state at 3 days postpartum was the best predictor of psychopathology at 6 weeks suggesting that it is possible to identify mothers at risk of postnatal mood disturbance. Mood disturbance in partners was not prominent and when present, it was elation rather than depression, possibly consistent with the effect of a supposed positive life event such as childbirth. Only two partners displayed symptoms of depression 6 weeks postnatally, suggesting that the mood disturbance experienced by mothers after childbirth may be more related to the biological and hormonal aspects of the event rather than the life event [19] Longitudinal study. These rates varied significantly by family type: men in stepfamilies had more than twice the rates found for men in traditional families before the birth and after the birth. Men's depressive symptoms were correlated with their partners' depressive symptoms before and following delivery. The correlations between mothers' and partners' depressive symptoms in the stepfather families before the birth and after the birth were higher than for the men in other family types before the birth and following the birth. The incidence of distress/dysphoria in women and men during mid-and late pregnancy is of concern. The patterns of incidence and onset of distress differed between ♀ and ♂. This difference is characterized by a gradual increase in distress in vulnerable ♀ from mid-pregnancy until after the arrival of the baby, while ♂ who report distress in mid pregnancy appear gradually to resolve this over time leaving a smaller residual group of troubled ♂ by the time the pregnancy is over T0 and T1 = 0.7%; T2 = 0.8%; T3 = 3.1%. On GHQ ♀ scores higher than ♂ antenatally and postnatally but not at T3. For ♀ and ♂ there was a positive significant correlation between their level of neuroticism and their depression scores at each of the four assessment points The prevalence of depression was measured by calculating the percentage of ♂ and ♀ who scored above the EPDS (♀, 6 wks postpartum), the BDI, or the GHQ (♀ and ♂, remaining timepoints) clinical cut-off points each assessment period. The incidence of self-reported depression in ♂ was consistently lower than in ♀ Theories for this gender difference include an under-reporting of depressed affect by men, either due to a real difference in the experience of depression poorer recall of symptoms by men expressing disturbed affect through different symptoms than those assessed on diagnostic interviews or self-report measures [24] 251 couples from Sydney. the sample sizes for the data analyses vary from 200 to 218 for the ♂, 230 to 238 for the ♀, and 212 to 218 for couples. Numbers vary depending upon whether the analyses inspect complete self-report data, caseness data, or a combination of both. ♂x = 29.1 yr ± 4.6 ♀x = 27.2 yr ± 4.2 Cross-sectional. EPDS, CES-D, DIS 6-7 wks postpartum.
11 ♂ met criteria for distress, 3 for depression only, 3 for comorbid depression and anxiety, 5 for anxiety disorder. Of the 208 ♂ providing data for both depression and anxiety modules of the DIS, 2.9% met criteria for depression and 5.3% for distress caseness. 16 ♀ met criteria for depression only, 6 for panic, and 5 for anxiety. Of the 230 ♀, 10.4% met criteria for depression and 16.1% for distress. EPDS scores: Distressed ♂x = 9.4 ± 5; Non-distressed ♂x = 4.1 ± 3.5. ♂ and ♀ differed significantly on x scores (♂x = 4.35 ± 3.72 vs. ♀x = 6.34 ± 4.33; p < 0.01) The EPDS is both reliable and valid for fathers. It discriminates between distressed and non-distressed fathers, using caseness of either just depression or depression and anxiety. Rate of depression in ♂ may at first seem low. However, when compared to large scale community studies it appears to agree with the general finding of lower rates of depression in husbands than wives [25] A 6-mo follow-up of a community sample of women who were evaluated for psychiatric disorders at 2 mo postpartum. 48  In the original sample, 17 ♂ (24%) were diagnosed with a psychiatric disorder at 2 mo postpartum. 2 of these ♂ were lost to follow-up. Of the 15 ♂, 9 (60%) remained symptomatic at 6 mo postpartum. 3 new cases were diagnosed at 6 mo. Anxiety and depression scores were elevated among ♂ in the index group, whether or not the ♀ were in remission at 6 months. Life stress was found to be correlated with ♀ depressive symptoms on the SCL90-R, with ♂ depressive symptoms, and with ♂ somatic symptoms.
The results of this study of a community sample of postpartum women and their partners indicates that mental health problems tended to persist for several mo. after the birth of the infant. The results of this study confirm other research showing that the partners of women with postpartum psychiatric disorders often exhibit mental health problems. Many of the fathers appeared to be suffering from chronic mental health problems, which continued to affect them after the birth of their children. However, even among fathers with no psychiatric diagnosis, those whose partners had a postpartum psychiatric disorder continued to report relatively high levels of psychological symptoms at 6 mo. postpartum EPDS, CES-D, POMS 6-8 wks postpartum. At the 6-week home interview the mother and father were separately administered the Diagnostic Interview Schedule: Depression and Anxiety modules ♀ meeting criteria for both depression and anxiety at 6 wks postpartum had a significantly higher antenatal EPDS score (x 11.7 ± 5.8) than those with just anxiety (x 8.3 ± 4.4) depression (x 7.0 ± 3.2). ♂ with just depression scored significantly higher on their antenatal CES-D (x 16.5 ± 18.2) than those with either no disorder postpartum (x 7.4 ± 6.2) or a mix of anxiety and depression (x 6.0 ± 6.8) Do not appear to be a clear pathway for the differential development of an anxiety or depressive disorder postpartum for ♀. A history of an anxiety disorder appears to be a greater risk factor for the development of postpartum mood disorder than a history of a depressive disorder. ADS-L scores: Group 1: Normal: 90% ♀ 98% ♂ Depressive: 9.5% ♀ 2% ♂ Group 2: Normal: 90% ♀ 97.5% ♂ Depressive: 10% ♀ 2.5% ♂ Group 3: Normal: 94% ♀ 96% ♂ Depressive: 6% ♀ 4% ♂ Stress reaction before prenatal testing Group 1: ♀x = 3.4 ± 0.9 ♂x = 3.1 ± 0.8 Group 2: ♀x = 3.4 ± 1.5 ♂x = 3.1 ± 0.8 Group 3: ♀x = 3.9 ± 1.3 ♂x = 3.6 ± 0.5 Stress reaction after prenatal testing: Group 1: ♀x = 3.1 ± 1.4 ♂x = 2.9 ± 1.0 Group 2: ♀x = 2.5 ± 1.3 ♂x = 2.6 ± 1.0 Group 3: ♀x = 3.3 ± 1.2 ♂x = 3.1 ± 0.5 ADS scores ≤ 23 normal ≥23 depressive. Questionnaire for stress total scores range from 1 (minimum stress) to 6 (maximal stress). Comparable analysis of depressive reactions before prenatal diagnosis showed no significant difference between the prenatal test groups neither for the pregnant women nor for their partners Simple effects revealed that between T0 and T1 there was a significant increase on all of the outcome measures with the exception of anxiety, and a change in the coping repertoire used. Between T0 and T2, there was a significant reduction in all outcome measures. In the present sample of men, pregnancy was associated with high levels of stress and anxiety, above that which would be expected for a non-psychiatric population. At pregnancy outcome, levels of stress, anxiety, and depression all increased irrespective of whether the outcome was a live birth or miscarriage. One year following outcome, anxiety and stress levels had fallen significantly below pregnancy levels, whereas depression levels, whilst showing a decrease compared to at the time of pregnancy outcome, remained significantly high compared to pregnancy The mean EPDS score was significantly higher in mothers than in fathers both at one week and at two months. New mothers experienced more blues symptoms, had higher overall mean percentage scores on the Blues Questionnaire than new fathers. The mothers' mean percentage score of blues for each day peaked on day4 after the delivery, while fathers' peaks on day 1 The younger age of onset of fatherhood was independently associated with higher HADS and GHQ-28 scores in a multivariate analysis. Symptoms in anxiety domains had a stronger association compared to those in depressive domains in both the HADS and GHQ-28 [33] 367 couples with an ART pregnancy. ♀x = 33. ♂ in the control group reported higher levels of depressive symptoms than ♂ in the ART group. Among ART ♂ in both groups, depressive symptoms ↑ after the baby was born. ♂ 's anxiety symptoms first ↓from pregnancy to post-delivery, and then ↑ at T2 in both ART and control groups ART is not a risk factor for the development of psychological symptoms in mothers and fathers to be [34] 11833 ♀ 8431 ♂ Postpartum depression in ♂ was strikingly high (10%) and more than twice as common than in the general adult male population in the US 17 of 23 ♂ scoring above the cut-off for depressive symptoms also scored above the cut-off for anxiety symptoms. T1 EPDS x = 6.8 ± 4.9 EPDS-P x = 8.2 ± 4.3 BDI x = 9.2 ± 6.8T2 EPDS x = 5.0 ± 4.8 EPDS-P x = 7.4 ± 5.0 BDI x = 6.4 ± 6.4 HDRS x = 5.4 ± 6.0 The EPDS-P was found to be moderately related to both a clinician rating of depression and the women's self-reported depression ratings. As expected, due to reliability of self-report data, the EPDS showed a significantly stronger correlation with the BDI and the HDRS than did the EPDS-P. Men whose partners had depression had significantly higher depression scores than did men whose partners had no depression. Maternal PPD affected study fathers in negative ways, as shown by higher levels of depression and parenting stress among men whose partners had depression. Paternal marital satisfaction was not associated with maternal depression at 2 to 3 months postpartum [ It was expected that ♀ showed more blues and depressive symptoms than ♂. This has also been found antenatally and in the first months postpartum. Two subscales of Blues Questionnaire's 'primary blues' and 'hypersensitivity' was most predictive for high EPDS scores at 2 months in new ♂, while in ♀ the subscale 'depression' was most predicted for depressive symptoms later on.  Low marital satisfaction increased the probability of depression during pregnancy in women and men. Among men low affective social support was associated with depression during pregnancy. The prevalence of depression during pregnancy was higher among ♀ and although most psychosocial and personal factors associated with depression during pregnancy were similar for both sexes, low affective social support and partner's depression were only related to ♂ depression. Depression in men is relatively common. There is a suggestion from these findings that depressive symptoms are even more common in the prenatal period than postnatally, although the proportion of fathers with high scores changes little across this period. Symptoms of anxiety were higher in T0, ↓ in T1 and ↑ in T2. Symptoms of depression ↓ throughout pregnancy, with a significant ↓ occurring from the T0 to the T1 and again from the T1 to the T2. it is noteworthy that the T2 seems to be a period of relative calm in terms of psychological morbidity, and significant ↓ both in anxiety and depression symptoms were observed. ART mothers of twins reported fewer symptoms of depression than control mothers of twins during pregnancy. The higher levels of depression and anxiety after delivery in both ART and control mothers of twins than in mothers of singletons confirm previous findings of an increased risk of post-partum depression associated with spontaneously conceived multiple births. Twin birth, but not ART, had a negative impact on the mental health of fathers. Results show no significant differences between paternal and maternal EPDS scores which indicates that depression is a problem for both women and men in the postpartum period. no significant differences between paternal and maternal perceived stress as indicated by the PSS scores.  [54] Prospective cohort. 551 ♂x 33.4 yr ± 5.9 . 57♂ who dropped out at 8 wks post-partum x 32.4 yr ± 5.5 Cross-sectional. EPDS, BDI, PHQ-9. All participants who scored above the BDI cut-off score of 10.5 or the EPDS cut-off score of 9.5 were invited to return for a psychiatric diagnostic interview (SCID-NP) Score of groups who completed the study: EPDS x 4.9 ± 4.3. BDI: x 3.8 ± 5.0; Score of groups who dropped: EPDS x 5.4 ± 5.2. BDI: Evidence suggested that postnatal depression in ♂ may have a later onset, probably following the occurrence of depressive symptoms in their partners. In contrast to ♀ who reported relatively high rates of depression during pregnancy and immediately following childbirth, depression in ♂ tends to ↑ over the first postnatal yr and reaches its peak at 12 months postpartum. [55] Recruited from 2 different hospitals. The incidence of depression was higher among ♀ than ♂ at T2, but was similar among ♀ and ♂ at T3; the incidence of depression ↓ during the first postpartum year for ♀, but the association is at the limit of statistical significance; psychosocial and personal factors associated with depression 1 year after childbirth were similar for both ♀ ♂ (marital satisfaction, partner's depression, pregnancy depression), negative life events were only related to ♀ 's depression. Lack of affective and confidant social support did not increase the risk of depression in either ♀ ♂. Depression: 5%, 4.5%. 4.3%; BD: 3%. 1.7%. 0.9%. Depressive episodes in fathers significantly associated with manic/hypomanic episodes during pregnancy and postpartum period; not 12 mo after birth. Delivery may act as a specific event whose effects decrease over time Bipolar episodes were common in men with depressive symptoms during their partner's pregnancy in the postpartum period and, to a lesser extent, 12 mo after birth. This population should be carefully investigated for manic and hypomanic symptoms. The high prevalence of bipolar related episodes may depend on the instrument used and on this specific period of life which might act as a stressor in association with genetic vulnerability, increasing the risk of highly heritable forms of affective disorders [60] 1562 ♂ 7 weeks postpartum Cross-sectional. EPDS, SCID EPDS score: 335 (85.6%) scored ≤ 10 and 199 (12.74%) scored ≥ 10. A random selection of the EPDS low scorers (n = 266) and all the EPDS high scorers (n = 199) were contacted to obtain permission to be assessed using the SCID diagnostic tool for depression. Thirty-one (16%) ♂ met the DSM-IV criteria for depression while 94 (49%) ♂ failed to meet these criteria. Sixty-seven (35%) ♂ were not currently depressed but were deemed at ↑ risk of developing depression.
The main finding of this study suggests that depression in ♂ in the postnatal period is associated with increased healthcare costs. In terms of incremental costs for each category of care, depression was associated with significantly ↑ community care costs [61] 99 fathers with diagnosed depressive disorders, 54 w/o Cross-sectional. To investigate association between paternal depressive disorder and family and child functioning in the first 3 mo of a child life (families seen at home 3 mo after birth). SCID, EPDS ≥ 10, AUDIT, DAS, IBQ, antisocial personality problems scale, perceived criticism in the couple relationship self-report.
Depression in fathers is associated with an increased risk of disharmony in partner relationship, reported by both fathers and their partners, controlling for maternal depression. Few differences in infant's reported temperament found in the early postnatal period Depressive disorder affecting fathers is associated with an increased risk of inter-parental conflict in the postnatal period. Paternal depression. Paternal depression seems to be associated with somewhat higher levels of difficulties in infant temperament [62] 260 Results generally show ↑ rates of depression compared to anxiety, in ♀ compared to ♂, and during pregnancy compared to T4. Depression was more prevalent than high-anxiety in ♀ either early in pregnancy or at T4. ♀ were more likely than men to show high-anxiety at T2 and at T3, but not during early pregnancy or T4.   There were no significant differences in the prevalence of PND or EPDS scores between the new ♀ and ♂. The results showed that there was no significant difference between ♀ and ♂ perceived stress, indicating that the ♂ experienced similar levels of stress as ♀ at postnatal period. Perceived stress and social support were key predictors of EPDS scores for both ♀ and ♂ during the postnatal period.
[65] Prospective cohort study. 551 couples. ♂x 33.4 yr ± 5.9 Cross-sectional. EPDS, BDI, SCID Prevalence of PND 4.9% (2.4% major and 2.5% minor) Postnatal depression in one partner correlated with postnatal depression in the other. This association has been consistently demonstrated but is not likely to be related to common risk factors. ♂ postnatal depression was predicted by life events and stress. ♀ appeared to be differentially adversely affected by ♂ early symptoms; ↑ levels of acute symptoms in ♂ appeared to be particularly linked to ♀ later distress while the reverse was not true for ♂. Symptoms of post-traumatic stress and postpartum depression were positively related within couples. Longitudinal. HADS-A, HADS-D. As part of that trial a repeated measures cohort study was conducted to identify changes in self reported levels of anxiety and depression between the ♂ in the intervention group and the ♂ in the control group from bl to six wks ↓ anxiety levels from bl to 6 wks were significant in the intervention group but were not significant in the control group. In the intervention group 12.4% of the ♂ had less anxiety from bl to six weeks postnatal compared to 11.4% of ♂ in the control group. Both the intervention and control groups reported ↓ antenatal anxiety at 6 wks postpartum the antenatal and postnatal depression scores remained unchanged at 4% in both groups.
The intervention may have contributed to the ↓ anxiety scores in the intervention group by providing timely, relevant information to assist the fathers. Most of the fathers in both groups did not register any depression either ante or postnatal with no real changes from bl 6 wks post test, suggesting that depression levels remained constant.
Mothers and fathers with depressive symptoms had a poorer sense of coherence and perceived their child's temperament as more difficult than mothers and fathers without depressive symptoms at 3 and 18 months. Post-partum depressive symptoms did not differ according to the parents' age, child's sex, first or not first child, SES or mothers' educational level.
Early parenthood has been studied thoroughly in mothers, but few studies have included fathers. Depressive symptoms were more common in fathers with senior high school educational level compared with those with higher education or 9-year compulsory school Longitudinal. EPDS, CBCLT0 = prenatally T1 = 2 mo postnatally T2 = 6 mo postnatally T3 = 8-9 yr postnatally The differences between ♂ and ♀ views remained significant considering both internalizing and externalizing problems in boys, and nearly significant regarding internalizing problems in girls. Regarding ♂ reports, ♀ depressive symptoms was associated with significantly elevated level of child's total and externalizing problems. According to ♀ reports, the finding was similar but for total problems, the difference lacks statistical significance. For internalizing problems, the difference between the groups with and without ♀ depressive symptoms was not significant according to either of the parents ♀ ♂ were found to display quite similar EE scores. Regression analyses showed that depression and couple relationship significantly predicted EE in ♀, but not ♂. High levels of depressive symptoms in ♀ predicted increased critical comments in ♂ and less warmth with their children The findings of the present study are of potential clinical importance, as the parenting characteristics identified by the assessment of EE and its constituent components are potentially amenable to clinical intervention. As these findings relate to the first year of a child's life the possibility is raised of useful early intervention for depressed parents and their children [86] 205 ♂x 32.63 yr ± 5.00 Cross-sectional. EPDS, PSS, MSPSS. EPDS score: x 5.77 ± 4.50. PSS score: x 45.36 ± 8.06. MSPSS score: x 12.21 ± 6.55 The frequency of depression in ♂ was 11.7%. Increase in the ♂ 's stress score was associated with increased rates of depression in them. The regression analysis suggested that perceived stress as a factor effecting depression is of high importance in predicting ♂ 's PPD the present study is the association between the time to marital separation and ♂ dyadic discord, mothers' and/or fathers' depressive symptoms, and ♀ parental stress during early parenthood. ♀ ♂ selfestimated less dyadic consensus, more depressive symptoms, and higher parental stress than those who were not separated.
The data from the present study showed an association between low dyadic consensus, depressive symptoms and parental stress during early parenthood, and an increased risk of marital separation 6-8 years after childbirth. This knowledge is important for health professionals and could be useful in developing interventions to provide parents with adequate support during pregnancy and early parenthood [88] 622 Using ≥13 as the standardized cut-off for probable case of depression, the prevalence increased as the pregnancy progress and reached a peak at T2, with 3.3% of the participants scoring above cut-off in T0, 4.1% in T1 and 5.2% in T3, respectively. ♂ antenatal depression, especially ♂ depression in late pregnancy, could significantly predict ↑ level of depression among the expectant ♂ in the postpartum period. [89] 102 ♂ recruited between the second (>24th week) and third trimester of their partner's pregnancy. ♂x 35.82 yr ± 5.95  Longitudinal. EPDS (T0: between the 2nd and 3rd trimester of pregnancy; T1: 4-6 wks postpartum) cut-off > 9, STAI.
EPDS score: T0: x 4.17 ± 3.59; T1: x 4.04 ± 3.23. STAI scores: x 49.61 ± 11.19 9.8% of the expectant ♂ showed signs of elevated depressive symptoms during their partner's pregnancy by having scores of 9 or more on the EPDS and are therefore at risk of being diagnosed with a minor or major depressive disorder. Considering our results, on the one hand, this could imply that after adjusting to the new life circumstances, fewer fathers tend to suffer from depressive symptoms postnatally compared to the prepartum which is consistent with the findings of previous studies. Perceiving the partner as more controlling was significantly associated with more depressive symptoms in the individual but also in his or her partner. Perceiving the partner as more caring was not significantly associated with fewer symptoms in either the individual or the partner, once other relevant variables were controlled for. Higher levels of depressive symptoms were also associated with having a more vulnerable personality, other coincidental stressful life events and having a more unsettled baby ♀ ♂ vulnerable personality traits, coincidental adverse life events and more infant crying and fussing were also associated with significantly more depressive symptoms. The quality of the intimate partner relationship is significantly associated with postnatal mental health in both women and men, especially in the context of coincidental stressful events including infant crying [91] 18,552 from the Millenium Cohort Study (MCS) Longitudinal. T1(9 mo): Rutter's 9-item Malaise Inventory (shortened version) T2 (3 yr): Child-Parent Relationship ScaleT3 (5 yr)/T4 (7 yr): Fathers' parenting activity (involvement) was measured using answers to the amount of parenting activities they undertook with their child Findings suggest that postnatal paternal depressive symptoms are associated with fathers' negative parenting.
Paternal depressive symptoms significantly predicted higher levels of father-child conflict. Paternal depressive symptoms were not associated with paternal involvement, suggesting that the quality of parenting is influenced by depressive symptoms, but the duration of time spent with the child is not altered. Both maternal depressive symptoms and marital conflict moderated the association between paternal depressive symptoms and father-child conflict Despite reports showing the huge costs of paternal depression, parenting interventions are still primarily targeted towards mothers. Authors advocate a more family-centred approach and provided that appropriate support and services are put in place, they suggest routine screening for postnatal depressive symptoms in fathers [92] 897 families; the sample was divided into three groups: (Group A) families with ♀ who have experienced physical/sexual abuse (32.8 yr ± 2.2); (Group B) ♀ with experienced emotional abuse/neglect (33.4 yr ± 2.5); (Group C) ♀ no traumatic experiences (31.4 ± 2.2).
Longitudinal. T0: SCL-90-RT1/T2: SCL-90-9, SVIA The results showed that ♀ with early traumatic experiences (Groups A and B) had significantly more maladaptive interactions during the feeding of their children, both at 3 mo and 6 mo of age, when compared to mothers who had not experienced traumas (Group C).SCL-90-R mothers' subscale scores showed a main effect of the group with no time-point effect and no interaction effect between time point and group. The ♀ in Group B had significantly higher scores at T2 than Group A on the somatization, depression, and paranoid ideation subscales. The scores of the ♀ in Group C on all SCL-90-R subscales were significantly lower than those of Groups A and B, both at T1 and T2 Some authors have suggested that sexual abuse can have a more severe impact on subjects' psychopathology and has more frequently been associated with psychiatric diagnoses (e.g., PTSD). It has also been evidenced that ♀ victims of emotional abuse have a higher risk of psychopathological (including depressive) symptoms This study showed an increased risk of offspring anxiety at 18 years of age after exposure to maternal antenatal depression at 18 weeks gestation. This association was not seen following exposure to paternal depression. These findings highlight the differences between antenatal depression exposures in different parents. This adds to support for a fetal programming effect occurring during pregnancy, leading to potentially long-lasting effects on the anxiety state of offspring.
[ and the risk of PPD emerged, both in ♀ than in ♂ group while distress ♀ levels are related to paternal one. Additional analysis regarding the association between the desire of pregnancy and the level of PPD suggests that there is a significant difference between ♂ who desired a child e ♂ who did not desire a child During this critical life event, some of couples of parents experience a high vulnerability and refer significant distress levels; mood disturbances and parenting stress in postpartum period represent high risks of parents and children well-being. Dysfunctional parenting has been assumed as an important risk factor in the development of psychological disturbances in adulthood and several studies have reported a significant correlation between maternal PPD and altered cognitive/affective child development.
[95] The test-retest reliability correlations between consecutive measurement points were at least moderate indicating that both ♀ and ♂ social and emotional loneliness were stable during the study period. Concerning ♂ social loneliness, similarly to ♀ the largest class consisted of fathers with very low and even continuously decreasing feelings of loneliness. These groupings revealed that the higher the loneliness was, the more the parents experience these other psychosocial problems Becoming a parent may increase both mothers' as well as fathers' feelings of social and emotional loneliness and these phenomena are highly associated with lower levels of marital satisfactions and higher levels of social phobia and depression [97] 807 couples Cross-sectional. EPDS (♂ cut-off ≥8; ♀ cut-off ≥ 9) EPDS ♂ scores: 110 (13.6%) scored ≥ 8. The x age of these ♂ 33.4 ± 5.7 yr.
The prevalence of ♂ depression at four months after childbirth was 13.6%. The factors that were significantly correlated with ♂ depression were the presence of partner's depression, low marital relationship satisfaction, pregnancy with infertility treatment, experience of visiting a medical institution due to a mental health problem, and economic anxiety [98]  The risk of PPD was 4 to 18 times higher for mothers and 3-9 times higher for ♂ of VLBW infants compared to mothers and fathers of term infants. Mean scores on the depression scales and prevalences of clinical PPD were higher in parents of VLBW infants than in parents of term infants, with ♀ in both groups at a higher level than ♂. The most important risk factor for PPD was the birth of a VLBW infant itself. Family related factors like SES, primipara, a pregnancy of high risk or with multiples were not as relevant as individual parental factors like sex, lifetime psychiatric diagnoses and social support Fathers with depression may be withdrawn while interacting with their infants and be less stimulating. They may adopt maladaptive patterns of parenting, thus potentially impairing their children's development [101] N = 13,822 Longitudinal. Cohort study EPDS > 12 at 8 wk and 8 mo after birth (both ♀ ♂). Child outcomes Rutter revised preschool: 42 and 81 mo.
Family factors (maternal depression and couple conflict) mediated 2/3 of the overall association between paternal depression and child outcomes at 3.5 yr. Similar findings when children were 7 yr old. In contrast, family factors mediated less than 1/4 of the association between maternal depression and child outcomes. No evidence of moderation effects of either parental education or antisocial traits.
This study suggests that the association between depression in ♂ during postnatal period and subsequent child behavior is explained predominantly by the mediating role of family factors. In contrast, the association between depression in ♀ and child outcomes is only explained to a small degree by these wider family factors and is better explained by other factors, which might include direct effects of depression on mother-infant interaction Predictor for depressive symptoms at postpartum, ♀ family sense of coherence, social support, and depressive symptoms during pregnancy changes in family sense of coherence and social support from pregnancy to 6 months postpartum; and partner's depressive symptoms; ♂ family sense of coherence and depressive symptoms during pregnancy, changes in family sense of coherence from pregnancy to 6 months postpartum, and partner's depressive symptoms were significant predictors of depressive symptoms at 6 months postpartum Partner's depressive symptoms significantly predict mothers' ♂ depressive symptoms 6 months postpartum, suggesting that an increase in depression in one partner leads to increase in the other. Prenatal depression was a significant risk factor for postnatal depression among both parents. Social support was only found to predict depressive symptoms at postpartum among the mothers, but not the ♂. Mothers had a comparatively higher level of social support than the ♂ across the perinatal period indicating that social support acts as an important external coping resource that can alleviate depressive symptoms at postpartum. Both stress and family and marital functioning may be moderated and mediated by other factors to predict effect on depressive symptoms. The paternal depression risk was measured as 4.3% in the prenatal period, and it was measured as 7.1% in the postpartum period. The EPDS average score was ↑ in the postpartum period. The results showed that low marital adjustment and work-family conflicts affect paternal depression risk. Also, ♀ depression risk did not affect ♂ depression risk, but↑ depression risk was found for ♂ that did not want the pregnancy [104] 885 ♂ 926 ♀. ♂x = 32.6 yr (20-51) Cross-sectional. EPDS (cut off ≥ 12) 6.3% of ♂ scored 12 or more on EPDS and 9.1% scored zero.
1.5% of couples reported depressive symptoms in both ♀ ♂ The prevalence of depressive symptoms in ♀ seems to be approximately twice that in ♂. Depressive symptoms in one parent were associated with a ↑ risk of depressive symptoms. Longitudinal. PSQI, EPDS At T1, 6.8% of ♂ and 13.4% of ♀ had clinically significant PPD. At T2, 9.7% of ♂ and 13.4% of ♀ had clinically significant PPD. At T3, 9% of ♂ and 13.5% of ♀ had clinically significant PPD. Of those ♂ who reported clinically significant PPD at T1, 26% also had clinically significant PPD at T2 and 50% had clinically significant PPD at T3. Of those ♂ who reported clinically significant PPD at T2, 39% also had clinically significant PPD at T3.
For both partnered ♀ and ♂ and for single ♀, depressive symptoms at 1 month after the birth of a child was associated with poorer sleep at 6 months postpartum, which was in turn associated with more depressive symptoms at both 6 and 12 months postpartum. Both ♀ ♂ postpartum depression were influenced directly and indirectly by parents' own anxiety levels and parenting stress as well as by the presence of depression in his/her partner. Although the two models are similar, they differ with respect to the role of parenting stress. The latter was shown to have an effect on maternal postpartum depression at 3 mo. postpartum, whereas it only influences paternal postpartum depression 6 mo. after the child's birth [107] Cohort 1797 ♀ 1658 ♂.  Almost one out of four fathers in our study experienced depressive symptoms. We discovered the occurrence of paternal PPD diminishes over the course of the 6-week post partum period. Fathers who were manifesting symptoms at 3 days resolved issues; perhaps, by adapting to parenthood, whereas first-time fathers who became depressed after 2 weeks and 6 weeks had, possibly, faced new challenges related to marital discord and parenting responsibilities. Maternal prenatal depression predicts maternal postnatal depression and paternal prenatal depression predicts paternal postnatal depression [112] 80 cohabiting primipara couples between 28 wk gestation and delivery Longitudinal. To describe course of depression in both ♀ and ♂ (and interrelation) from the 3rd trimester of pregnancy through 6th mo. CESD ≥ 16 ♀ EPDS ≥ 12 ♂ EPDS ≥ 10. BL 1, 3, 6 mo postpartum Depression. Prenatal period: ♂ 20.5% ♀ 32.1%; 1 mo ↓ in both parents; 3 mo ♂ ↑, ♀ ↓; 6 mo. ♂ ↔, ♀ ↓ Average depressive symptoms severity declined linearly and similarly in both ♀ and ♂ For both ♀ ♂ symptoms severity ratings and classification were stable across time, with prenatal depression persisting through 6 mo. 75%♀ 86%♂. Prenatal depression in ♂ predict worsening depressive symptoms severity in ♀ across first 6 postpartum mo.
but not viceversa. ♂ experienced depression, reported loss of control and powerlessness, indicating difficulties with handling stress, feelings, and demands. ♂ with depression reported having no time to reflect over their situation, and that they found it difficult to cope with all conflicting demands and feelings of not being good enough, either at work or as a parent. Several ♂ reported that their partners were or had been depressed during pregnancy and/or postpartum From T1 to T5, anxiety and depression symptoms ↓. From T5 to T6, anxiety and depression symptoms ↑. At T1, ♀ had more anxiety anddepression symptoms than did ♂. No other gender effects were found for time regarding both symptoms. [119] Data from a parent-child cohort of a prospective longitudinal study. 700 ♀, 646 ♂, and 583 couples. ♂x = 34.6 yr; ♀x = 32.3 yr.
> 11% of ♀ and ≈5% of ♂ reported depressive symptoms and that ≈16% of children had at least one parent with depression. ≈8% of both sexes reported feelings of incompetence with rather strong associations with depressive symptoms for both ♀ and ♂. The reason may be that some of the questions in the incompetence subscale identify feelings that can be associated with depression [120] 438 ♂x = 34.1 yr ± 6.7 Cross-sectional. BDI-II ( ≥14 mild/major; ≥20 moderate/major; ≥29 severe/major), EPDS (cut off ≥ 12), GMDS The items measuring depressive equivalents and those measuring traditional depressive symptoms correlated highly witheach other. This finding highlights the coexistence of traditional depressive symptoms and depressive equivalents in ♂. 28% of ♂ in the present study reported depressive symptoms above the BDI-II cut-off for mild depression, almost 14% above the BDI-II cut-off for moderate depression. Fathers with elevated psychological distress were more likelyto endorse reluctance to talk to others about their moods oranxieties, and reluctance from family or friends to talk aboutemotional aspects of pregnancy and the postpartum period asbarriers to seeking help to improve mental health duringpregnancy and following the baby's birth.
[122] 22 ♀; 19 ♂ but only 2 ♂ attended the focus group. ♀x = 31.3 yr ± 4.70 Longitudinal. Objectives were: explore the needs of ♀ in the year following childbirth; to compare these needs between ♀ who did not have a psychological disorder and who lived a PPD; and to compare the needs expressed by ♀ with the perception of professionals and fathers about the mothers' needs.EPDS T1: 1 mo PP; T2: 6 mo PP; T3: 1 yr PP EPDS score: T1: 11.6 ± 6.61; T2: 10.0 ± 5.02; T3: 7.00 ± 3.74 (The results concerning the comparison of the ♀ needs and the ♂ perception about the ♀ needs should therefore be interpreted with cautious, given the low number of ♂ who attended) ♂ play a central role in the psychological wellbeing of the ♀. Some couples had arguments because of the new organization. Many ♀ felt supported by their partner and said it was great to chat with them. Other ♀ would have liked them to be more considerate and present. For ♂, postnatal period appeared to be punctuated by the baby's rhythm; while for ♀, it also seemed to be marked by their own pace. ♂ understood mothers' need for sharing and for psychosocial support and thus were aware of the importance of continuing to have a social and family life. For them, are in the same boat which strengthens the ♀ ♂ complicity of the couple; this did not seem to be always true for ♀.
[123] 196 ♂x = 32.0 yr ± 5.0 Longitudinal. ♂ depression in the prenatal and early postnatal period. EPDS: T1: 20 we gestation; T2: the first few days; T3:1 mo PP; T4: 2 mo PP. Also investigated the association of ♂ depression in the prenatal and early postnatal period with child maltreatment tendency at 2 mo PP with CMS EPDS score: T1:9.7%; T2:8.0%; T3:6.6; T4:8.8. On the CMS, 36♂ (18.4%) met criteria for child maltreatment tendency. The impact of ♂ depression on child maltreatment tendency changed depending on the timing of the depressive episode's onset Current ♂ depression in the early postnatal period was associated with child maltreatment tendency at 2 mo PP. To prevent childmaltreatment, early detection of ♂ depression and an appropriate initial response by healthcare providers is exceedingly important   Predictors of high PPD symptoms in ♀ included low household income, high prenatal depressive symptoms and postnatally, low social support (from fathers, presumably) and higher number of stressful life events experienced. For ♂ similar predictors were identified, including low household income, high prenatal depressive symptoms, and low postnatal social support (from mothers, presumably) and postnatal smoking [131] 306 ♂x = 27.80 yr ± 6.95 Longitudinal. Possibly/Probably Depressed EPDS > 9 and Nonsymptomatic Fathers EPDS ≤ 9. T1: interview at 1 mo. after birth; T3: 12 mo. after the child's birth.
♂ reported low mean levels of depressive symptoms overall at both T1 x = 4.15 ± 4.26 and T3 x = 3.88 ± 4.02. At both T1 and T3, 11% of the sample was above cutoffs for probable or possible depression and 89% of the sample was under the clinically suggestive cutoff of 9 on the EPDS. There was substantial range and variability in depressive symptoms, with 11% of the sample possibly or probably depressed at each time point. Very few ♂ screened high at both time points; only one ♂ had possible depression at both T1 and T3, and six ♂ had probable depression at T1 and T3 Fathers display low average depressive symptoms, fairly low perceived stress Longitudinal. HADS to assess psychological distress in expectant parents, before and after receiving information about PND. Comparison of Groups A and B (two different procedures of information giving), psychological distress, and levels of anxiety and depression HADS: (T1) participants in group A had a higher rate of health-related worry. Differences in the other dimensions of psychological distress were not observed between participants from group A and group B at T1. General anxiety decreased among the participants in group A but was unchanged in group B. The rate of depressive symptoms was unchanged over time in both groups. At T1 ♀ had a higher degree of depressive symptoms than ♂ and 2.6% ♀ vs. 0.5% ♂ were categorized as clinical cases. These rates were unchanged at T2 More distinct two-stage process (more time and information, 30-45 min) reduced anxiety (group A), while less distinct two-stage process (less time and information, 10-15 min, group B) left it unchanged.
♀ more worried and depressed than ♂ Longitudinal. Couples agreed to take part in a year-long, Longitudinal study in which they would be interviewed at four time points: T1: 3rd trimester of pregnancy; T2: 1 mo PP; T3: 4 mo PP; T4: 9 mo PP. PPD is misured with PDSS For both ♂ ♀ PPD scores were significantly lower at 4 mo PP in comparison to their depression scores at 1-month PP. Co-parent depression was also explored as a potential control variable; analyses indicated co parent depression did not significantly predict PPD for ♀ or for ♂ at either 1 mo or 4 mo PP Feeling self-efficacy as a parent (parenting efficacy) is linked to numerous positive outcomes for new parents. Conversely, perceived inability to meet expectations is associated with negative mental health consequences for ♀ and ♂. Parenting efficacy is negatively associated with PPD for both ♀ and ♂ throughout the transition period. ♀ and ♂ whose parenting efficacy experiences were more negative than expected reported higher levels of PPD at 1 mo PP. This effect dissipates for ♀ but not ♂, by 4 mo PP, suggesting differences in the experiences of ♀ and ♂ during this transition Approximately 85-90% of the parents in the FinnBrain Cohort reported low levels of depressive or anxiety symptoms at any trimester. This is in line with several previous studies showing that most parents in the general population report only minimal or mild symptoms during pregnancy and the PP. ♀ with low levels of depressive or anxiety symptoms were more often living with the ♂ of the child, smoked less frequently, and were expecting their first child more often than ♀ with high or changing levels of depressive or anxiety symptoms. There were no significant differences on demographic characteristics between participants who completed all three questionnaires and those who dropped out at T2 or between those who completed all three questionnaires and those who dropped out at T3. There was significant difference on prenatal depressive symptoms between ♂ who completed all 3 questionnaires x = 4.74 ± 2.97 and ♂ who dropped out at T2 x = 5.53 ± 3.88. No difference on prenatal depressive symptoms was found for ♂ who completed all 3 questionnaires and those who dropped out at T3 x = 5.32 ± 3.70. At T2, ♂ PPD symptoms were associated with ♀ PPD symptoms.
Effective assessment and interventions targeted at preventing or identifying and reducing ♂ PPD and improving father-infant relationship would help to lower the risk of infant disorders and poor development. Strategies improving the ♂ mental health during antenatal period and their partner's psychosocial well-being may also reduce paternal postpartum depression.
[137] 580 ♀x = 32.77 yr ± 5.11; 385 ♂x = 35.14 yr ± 5.07 Cross-sectional. PSS; EPDS ≥ 10. The main objective was to analyze the relationship between parental perception of child vulnerability in infants and perception of parental competence, considering the role that PPD and parental stress exert in that relationship.
PPD ♂x = 4.54 ± 3.89; ♀x = 5.86 ± 4.77. Regarding postnatal depression, both globally and differentiating between ♀ ♂ the averages were below the reference cutoff point for this variable. So this population is predominantly healthy in terms of PPD the results revealed an association between parental perception of their child's vulnerability and parent's perception of parental competence through depression and parental stress.
The relationship between parental perception of child vulnerability in infants and perception of parental competence is linked to the association between parental perception of child vulnerability and increased PPD and experienced stress   ART parents may experience more psychological difficulties during the transition to twin parenthood than SC parents. ART mothers appear to be more at risk of high levels of postpartum depressive symptoms [146] ♂ 3656; No correlation between paternal depression and maternal NVP, but a significant association was found between moderate and severe maternal NVP and paternal anxiety Depressive symptoms during pregnancy more represented in ♀ due to possible underestimation of paternal depressive condition. ♂ display different depressive symptoms from ♀. Risk factor related to pregnancy, low social support, personal psychiatric risk factors, negative life events would have predicted depressive symptomatology during pregnancy in both ♀ and ♂. Marital dissatisfaction, personal history of depression and personal trait anxiety associated with ↑ depression during pregnancy. No association between SES and depressive symptoms during pregnancy for ♂ Mothers obtained ↑scores than fathers on psychological distress but ↓ for resilience. Mothers of SGA newborns were more distressed than the other groups but there were no differences between fathers of SGA vs. The prevalence of depression in fathers was 13.76% at 2 mo and 13.60% at 6 mo postpartum. Men with depression during their partner's pregnancy were 7 times more likely to have depression 2 mo postpartum. Depression at both antenatal and 2 mo postpartum assessment was associated with increased risk of depression at 6 mo postpartum. Older age, poor sleep quality at study entry, worse couple adjustment, having a partner with antenatal depression, and elevated parental stress were associated with depressive symptoms at 2 mo postpartum. Poor sleep quality, financial stress and a decline in couple adjustment were independently associated to depressive symptoms at 6 mo postpartum The psychosocial risk factors identified provide opportunities for early screening and targeted prevention strategies for fathers at risk for depression during the transition to parenthood [155] 290 Cross-sectional. 3 mo postpartum, mothers and fathers completed self-report questionnaires to evaluate symptoms of depression (EPDS) and anxiety (STAI-Y), and a form to gather socio-demographic data. At 3 mo, mother-infant couples were video-recorded and evaluated with the Child-Adult Relationship Experimental Index (CARE-INDEX) 2.9% of the fathers had scores exceeding the clinical cutoff (≥12) for depression; 21.7% of fathers had scored high on state anxiety (cutoff ≥ 39), and 11.6% of fathers had scored high on trait anxiety (cutoff ≥ 42). There were also significant associations between paternal depression and anxiety and mother-infant interaction style Paternal anxiety and depression affect the quality of mother-infant interaction [158]  Longitudinal. Mothers and fathers were evaluated at baseline during early pregnancy (T1), the second trimester (T2), and the third trimester (T3) as well as at 1 month (T4), 6 months (T5), and 1 year (T6) postpartum.531 couples (n = 1062) successfully completed all 6 assessments until 1 year postpartum. Parameters assessed: EPDS, STAI, WHOQOL-BREF Post hoc contrasts for depression scores showed in fathers significant ↑ from T4 to T5 and ↓ from T2 to T3. Significant changes in anxiety symptoms from T1 to T6 in both mothers and fathers. Among men, increasing levels of depression and decreasing scores in the HRQoL social relations domain were observed during the first year after childbirth.
↑ depression and anxiety risks and ↓ HRQoL physical health and social relations domain scores throughout the perinatal period: > experienced than first-time fathers  Mean scores of the GAD-7 are above the norm values for the general German population, but below those for samples in primary care, with 6.1% reporting moderate and 1.6% reporting severe levels of anxiety. 13.5% showed a positive cutoff for depression. The mean score of pregnancy-related worries was low, with only 0.8% of the sample reaching a total score of 3, indicating less than major worry ↑Parental mental health problems (depression and anxiety) associated with lower levels of parental responsiveness, in turn related to poor parent-infant bonding Experienced mothers reported more fragmented sleep and perceived having worse sleep quality than first-time mothers, paternal sleep did not differ as a function of parental experience Longitudinal. EPDS at T1 (during pregnancy) and T2 (8 weeks postpartum).
Socio-demographic characteristics, relationship factors, and health behaviors were assessed at T1. Perceived social support was measured with the short version of the Social Support Questionnaire (F-Soz U-14); The short version of the Partnership Questionnaire (PFB-K) was used to assess relationship satisfaction During pregnancy (T1), the mean EPDS score was 3.9 ± 3.6). According to the standard EDPS cut-off scores, 50 expectant fathers (5%) screened positive for minor depression (≥10) and 40 (4%) for major depression (≥12).
At the postpartum (T2) assessment, x EPDS score was 3.5 ± 3.3. Of those participating in the T1 assessment, 20 (2%) screened positive for minor depression and 22 (3%) for major depression Perceived social support and relationship satisfaction appeared to be protective against paternal depression  Of the fathers, 11.5% had depressive symptoms (EPDS ≥ 12). The association between depressive symptoms and parental stress was moderate for fathers.
Thirdly, of the RQ subscales, only the preoccupied attachment style was associated with depression, as shown by the difference in scores between depressed and non-depressed parents, while no differences between the groups were found on the remaining subscales (i.e., secure, avoidant or fearful). For the fathers, parental stress in the areas of social isolation and health problems, as well as the preoccupied attachment style, were the best predictors. 83% of the pregnancies in which fathers reported postnatal depression were preceded by a preconception history of mental health problems. Perinatal depression was consistently higher in those with ahistory of persistent mental health problems across adolescence and young adulthood thanthose without The mediation effect of negative birth experiences in the association between mode of delivery and postnatal wellbeing highlights the need to take steps to reduce the trauma associated with giving birth by caesarean section [179] 1023 fathers at 1-month postdelivery, x age: 32.9; 1330 fathers at 6 month postdelivery, x age: 32.8 Longitudinal. Paternal post-partum depression to assess with EPDS at 1 and 6-month postdelivery and association with covariates.
Prevalence of paternal postpartum depression was 11.2% (115) 1 mo postpartum. Associated factors: history of mental health disorders before pregnancy, psychological distress during pregnancy, low income, and infant disease under medical treatment. At 6 mo prevalence was 12.0% (N = 160). Associated factors: psychological distress during pregnancy, unemployment, and maternal depressive symptoms.
1-and 6-mo postpartum, psychological distress during pregnancy and socioeconomic difficulties are factors associated to postpartum paternal depression [180] Fathers sample size vary from 9846 at 18 weeks gestation (x age: 30.40) to 1951 at 21 years post-partum (x age: 53.34).
Longitudinal. Paternal post-partum depression to assess with EPDS at 10 timepoints (first at 18 weeks gestation, last at 21 years post-partum). 14915 have at least one EPDS assessment, with 4067 having all 10 assessments and 1476 having zero.
The greatest proportion with probable depression occurs at 21 years post-partum (9.17% of fathers with EPDS ≥ 13 and 20.30% of fathers with EPDS ≥ 10) while the lowest proportion is at 8 months post-partum (2.96% with EPDS ≥ 13 and 7.31% with EPDS ≥ 10).
A strength of the study is the size of the population, but the EPDS does not assess the duration and intensity of depressive symptoms and, in addition, approximately 10 years elapse between the measurement at timepoint 9 and timepoint 10, and parental depression may relate to the adolescent period of the children 32% of fathers were at-risk of developing a paternal affective disorder. Three different clusters were found:"psychologically healthy men" (68%) with low levels of symptoms on all the scales; "men at risk ofexternalized behavioral problems" (17.1%), characterized by one or more addictive or risky behaviorsand moderate levels of scales scores; and "men experiencing psychological distress" (14.9%), with thehighest scores on all the scales. A significant association emerged among the perceived stress, maritaladjustment, and cluster membership [183]  Parents of infants hospitalized in the NICU had significantly more symptoms of depression than parents in the control group for the first three days after birth. 3 weeks later, even if the EPDS scores for the study group were still slightly higher than those of the fathers of healthy infants, the difference between the groups was not significant    First study: longitudinal analysis of MAPP data identified 5 characteristic profiles of ♂ 's patterns of depressive symptom severity and presentation of anger. Profiles indicating pronounced anger and depressive symptoms were associated with fathers' lack of perceived social support, and problems with coparenting and bonding with infants. Second study: MAPP data were combined with 3 other Australian cohorts in a meta-analysis of associations between fathers' self-reported sleep problems up to 3 years postpartum and symptoms of depression, anxiety and stress. Adjusted meta-analytic associations between paternal sleep and mental health risk ranged from 0.25 to 0.37 MAPP represents a unique study with recruitment of men approaching the peak age for entering fatherhood in order to specifically understand preconception risks and protective factors associated with a normatively timed transition to fatherhood. Despite calls for greater preconception engagement with prospective fathers, psychological and social factors that prepare men for fatherhood are vastly understudied compared with the equivalent in women ♀ experience both a decrease in average depression symptom scores and probability of screening positive for depression. ♂ did have a small and significant ↓ in EPDS scores from initial assessment to 1 mo after discharge, the probability of a positive depression screen remained the same across time [196]  ♂ undergoing a MAR pathway had ↓ depressive-anxious and stress symptoms than the control group from the general population without infertility. The finding that men undergoing MAR reported lower depressive-anxious symptoms than control ♂ was somewhat unexpected. An explanation for this surprising result might be that the prevalence rates of anxious and depressive symptoms significantly ↑ also in the general population during the pandemic [202] A cohort study was completed between 2015-2019. For those with severe comorbidity, the prevalence started from 0.47% at baseline rising to 3.0% at the 12 mo. postpartum and remaining consistent to 3.3% at 24 mo. postpartum. The prevalence of paternal dep ression symptoms (EPDS > 9) increased from birth to 6 mo., from 4.0% at baseline within the first 3 wks postpartum to 11.5% at 3 mo. postpartum and 11.7% at 6 mo. postpartum. Rates decreased slightly to 10.8% at 9 mo., 10.3% at 12 mo. postpartum and stabilized thereafter to 24 mo. The prevalence of anxiety symptoms (STAI > 38) followed a similar trend starting at 8.8% at bl increasing significantly to 22.2% at 3 mo. and 21.9% at 6 months postpartum and stabilizing to 20.4% at 24 mo. postpartum were lost to follow-up Longitudinal. BDI, STAI PSQI at T1: pre-treatment fertility, T2: post-treatment ferility, T3: 9-12 we after pregnancy test Mean psychological distress scores for the total sample at baseline were x = 10.0 ± 8.6 for depressive symptoms, x = 37.3 ± 10.9 for state anxiety, and x = 16.5 ± 9.1 for infertility-related distress. PSQI global scores were statistically significantly associated with state anxiety and depressive symptoms Poor sleep quality is a prevalent problem among couples undergoing fertility treatment and is associated with psychological distress and possibly with pregnancy outcomes. Success rates after fertility treatment remain moderate, and poor sleep quality, a potentially modifiable factor, could be relevant to screen for and treat among couples undergoing fertility treatment [204] 543,555 ♂ Longitudinal. Descriptive prospective study design; data from the Danish National registers. Perinatal psychiatric episodes assessed as incidence of first-time and prevalence of recorded in-or outpatient admissions for any mental disorder and redeemed prescriptions for psychotropic medication in ♂ at T1: 9 mo before birth, T2: until 12 mo after birth Prevalence proportions for fathers psychiatric in-and outpatient episodes showed an increasing trend over the perinatal period and were marginally higher PP compared to pregnancy. No difference between the periods for incidence of prescriptions for psychotropic medication. Psychiatric disorders in expecting and new fatherhood were mainly treated in primary care with cumulative incidence of prescriptions for psychotropic medication of 14.56 per 1000 births during the first year of fatherhood Becoming a father did not appear to trigger a substantially increased risk of severe psychiatric disorders, as it has been observed for new mothers [205] 529 ♀x = 32.5 yr ± 4.1 92 ♂x = 34.1 ± 5.3 Cross-sectional. PHQ-9; GAD-7; PSS PHQ-9 x = 3.0 ± 3.3; GAD-7 x = 2.5 ± 3.1; PSS x = 21.4 ± 6.3 There is a high prevalence of high-risk health behaviours in ♀ ♂ actively trying to conceive or planning to achieve pregnancy soon. Health promotion should be a key component of preconception health interventions for both ♀ ♂ as part of a life course approach to optimizing population health [206] FICare Further studies should focus on possible pathways of the association between paternal ACE (adverse childhood experience) and mental health problems, which may help develop an intervention to prevent postpartum depression and anxiety in fathers with ACE [208] 352 couples Longitudinal. EPDS cut-off ≥ 12, T1: prenatal, T2: post-partum EPDS scores ♂: T1: x = 35 ± 9.9, T2: x = 76 ± 21.5 Our study provided that the mechanism of prenatalmarital satisfaction and ♀ prenatal depression that best predicted ♂ postpartum depression. These findings suggest that the prenatal period is the ideal time for PPD. Considering the quality of marital relationships and couples' perinatal mental health are necessary to promote fathers' mental health. Addressing ♂ ♀ PPD and considering marital satisfaction cooccurrence is essential in expecting families' research and practice [209] 100 ♂x = 31.34 yr ± 4.38 Longitudinal. Correlations between the Baby Care Scale-Antenatal BCS-AN at T1(Prenatal) and the Baby Care Scalepostnatal BCS-PN at T2 (Postnatal) and measures of anxiety (STAI-S) and depressive symptoms (EPDS) Regarding the BCS-AN and BCS-PN criterion validity, significant medium-sized correlations were obtained between the BCS-AN and BCS-PN and measures of anxiety and depressive symptoms and measures of father-infant emotional involvement. Significant associations between mental health problems of ♂ and frequency of care provided by the ♂ to the infant This study suggested that the BCS-AN and the BCS-PN are reliable multidimensional self-reported measures to assess the involvement of father in infant care during pregnancy and the postpartum period The aim of this pilot study was to investigate the prevalence of ♂ ♀ perinatal depression and additionally identify psychosocial and biological risk factors. Despite a relatively small sample size, we found that ♂ are also at risk of developing peri-and postnatal depression, consistent with previous studies. Cross-sectional. EPDS cut-off score ≥ 13 EPDS scores♂: x = 6.45 ± 4.25. PPD ♂ 7.5%. The predictors of paternal depression were paternal parenting satisfaction and selfefficacy, maternal depression and whether the pregnancy was planned ♂ ♀ depression were positively correlated and were predictive factors for one another. Healthcare professionals should screen both ♂ ♀ for depression in the early PP and provide targeted support during time in hospital following birth. The focus of future interventions should be on both parents rather than just mothers [212] 177♂ Longitudinal. EPDS cut-off ♂ ≥ 13. T1: 3 mo, T2: 9 mo, T3: 12 mo postpartum EPDS results revealed a general decrease in Perinatal Depression across the year. Considering birth weight, ELBW (Extremely low birth weight) parents showed higher PND levels at T1 and a higher reduction of symptoms over time than VLBW (Very low birth weight) and FT(full term) ones. Given also parental role, ELBW ♀ showed higher PND levels at T1 and a higher decrease of symptoms over time than VLBW and FT ♂ ♀ Findings suggest that premature birth in relation to its severity may lead to different affective reactions in ♂ ♀; particularly ♀ in case of more serious preterm condition, are at higher risk for PND in the first trimester, however showing improvement over time. Interventions should be promoted, andtailored, according to the risk connected to severity of prematurity.

Discussion
In this systematic review, we sought to identify the prevalence of depression in expecting fathers and to see whether the occurrence of depression in the pregnant or delivering woman matches the development of depression in the father. We found a figure of around 5% for depressive symptoms in fathers of newborn children or in expecting fathers. Despite the low occurrence of depression in men who are partners of child-bearing women, the entity of paternal depression has the right to be framed within the current nosographic systems. We also found that depression may co-occur in the same couple, but in a very low, though not negligible, amount-around 1-2% [173]. It is more probable that depression in expecting mothers and fathers follows its own course, while in some instances, it has been shown that the presence of depression in one member may predict levels of depression in the other.
Despite the fact that in the DSM-5 [213], the issue of male or female depression is not fully clarified, some studies point to there being gender-related symptom differences for depression [214,215]. It is possible that such symptom differences are amplified by the condition of expecting a child, with the risk factors and the characteristics of depression differing between women and men [152]. Seeing one's body changing in shape, whether one's own or one's partner, may have a disconcerting effect in both, similar to what one has already experienced during his/her transition from adolescence to adulthood. This could induce someone to feel awkward about oneself or about their partner. In turn, this may ensue in a declining couple adjustment, which is independently associated with depressive symptoms 6 months postnatally in men during their transition to parenthood [154]. The finding of a differential response to antidepressant treatment between the two genders offers hope for the personalization of depression with respect to diagnosis and treatment [216,217].
There are data for both coordinated depressive symptom manifestation within a couple and for the disjoint occurrence of depression in couples. The former is suggested by the fact that having depression in a partner increases the odds of developing depressive symptoms in the other, and this holds true for both women and men [115]. During the postpartum period, the mean severity of depressive symptoms declined linearly with similar slopes in both men and women [112]. While prenatal depression in fathers predicts the worsening of depressive symptoms in the new mother across the first six postpartum months, which speaks in favour of the former hypothesis, this is not true for the opposite [218], which supports the latter [112]. No association between depressive symptoms was found between men and women [114,219]. Longitudinal patterns of psychopathology differ between men and women; for men, the early phase of pregnancy is the most difficult period in the transition to parenthood, while prenatal EPDS scores predicted postnatal scores in both men and women independently [129]. Parents whose parenting efficacy was more negative than expected displayed higher depression levels one month post-delivery; four months post-delivery, this effect disappeared in women, but not in men. This suggests that the two genders experience their transition to parenthood differently [134]. Furthermore, Nishimura and Ohashi found no association between maternal and paternal depression [53]. The results of these studies speak against the hypothesis that in couples, depression co-occurs in both members or that it has a similarity in its course. Yet another Japanese study found a majority of prenatal and postnatal parents (83%) not to be depressed, while a very small proportion (1.34%) of both parents were depressed, with 10.0% of new mothers and 5.7% of new fathers having depressive symptoms [173]. Hence, only in a very small proportion of couples did depression coexist in both members.

Limitations
The literature included in this systematic review used very different methodologies, including the instruments used, the time of observation, outcomes (some included psychosocial factors and others not, different parities), and the design (cross-sectional and longitudinal studies were prominently represented; the former do not allow for probing causality, while the latter employed different assessment timepoints). This rendered the data unable to be meta-analysed. Furthermore, the extensive use of the EPDS in men, an instrument that has proved valid for perinatal and especially postnatal depression in women, subtracts from the validity of the data. The male variant of the questionnaire has found little application heretofore (just two studies among those eligible, i.e., Moran and O'Hara, 2006; [41,69], and its reliability compared to the original women's version seems questionable [41]. The EPDS provides three different cutoffs according to severity and probability, thus rendering the very concept of depression fragmentary. Different studies used different cutoffs, often chosen arbitrarily-for example, different cutoffs for fathers and mothers (9 for fathers and 10 for mothers [130] and 6 for fathers and 8 for mothers [195]; this would have affected the results. Finally, we used only two databases/registries. The inclusion of more databases could have increased the final output; however, it would not have dramatically changed the conclusions.

Conclusions
Depression in couples expecting a baby or having had a newborn recently occurs disjointly, although depression in one member may affect depression in the other. Paternal depression is an entity with its own clinical dignity, despite its low occurrence (around 5%). The studies dedicated to this issue use poorly validated specific instruments, different methodologies, different assessment timepoints and follow-ups, unstandardized cutoffs, and different patient interview methods (i.e., vis à vis interviews, telephone calls, internetbased surveys, etc.). There is a need for the standardization of the methods, including outcomes, assessment tools, and follow-up intervals, and a focus on clinical and social measures that may constitute predictors of depression in men (and women) undergoing their transition into parenthood.

Conflicts of Interest:
The authors declare no conflict of interest.