Paternal perinatal mental disorders are inextricably linked to maternal and child morbidity

While women and their offspring dispro-portionately bear the morbidity and mortality burden of perinatal mental disorders, men should not be forgotten in perinatal health care settings. Yet historically, as emphasized by Howard and Khalifeh1, they have been overlooked. Compared with maternal men-tal disorders, there has been scant investigation of the prevalence, pathogenesis, risk, impact and economic costs of common men-tal disorders in fathers during the perinatal period, and of targeted interventions that could inform family-focused service deliv-ery models. Over the past five years, the focus has somewhat shifted, and a stronger lens has been cast on men, especially with respect to perinatal depression and anxiety. This is coupled to the recognition that pregnancy, birth and fatherhood directly influence men's mental health and well-being. Notwithstanding, paternal perinatal depression and anxiety are not recognized as discrete diagnostic entities in the DSM-5. The lack of explicit diagnostic criteria has led to heterogeneity in the way these conditions are defined, and contributed to var-iability in research findings. The prenatal, labour and delivery, and postnatal periods are characterized by psychological, emotional, biological, social and role changes that signal the transition to fatherhood. In a substantial proportion of fathers, this transition is also associated with serious and impairing mental health concerns. Perinatal mood and anxiety disorders are common in men and, like in women, can lead to cognitive, developmental and behavioural problems as well as to mood and anxiety disorders in the offspring2. Prevalence estimates for depression dur-ing pregnancy and up to a year postpartum are 8% in men, nearly twice the rate in the general adult male population. The prevalence averages 16% for any anxiety disorder in the prenatal and postnatal periods, a rate that is comparable with that in the general population3, 4. However, prevalence rates of anxiety in fathers during the perinatal period are highly variable, ranging from 2.4% to 51%. This reflects, to some extent, cross-study methodological differences in measurement, sampling, eligibility criteria, study setting, and cultural factors5. It should be noted that the rates of depression and anxiety in men and fathers are likely to be under-estimates, in view of symptom under-reporting by men. Although the etiopathogenesis of paternal perinatal depression and anxiety has not been elucidated, it is plausible that a complex interrelationship exists among individual-level biological predisposition (e.g., genetic, epigenetic, neuroendocrine determinants), psychosocial variables, relational stress, and environmental and social factors. It is notable that maternal and paternal perinatal depression are mutually interdependent. Maternal depression is one of the most common predictors of paternal -perinatal depression, while mothers whose partners are depressed are more than four times more likely to have worsened symptoms by six months postpartum6. In men, there is also a high coexistence of anxiety and depression, with high anxiety levels during the perinatal period contributing to depression, stress and perceived diminished self-efficacy in coping with the challenges of fatherhood4, 5. Unfortunately, our understanding of the trajectories of co-occurring depression and anxiety in relation to perinatal stage, and of the precipitating, perpetuating and maintaining factors for depression-anxiety occurrence in the prenatal and postnatal periods, is very limited. Longitudinal studies which prospectively assess mood and anxiety disorders and symptoms in men prior to pregnancy and at repeated intervals through-out the perinatal period, and which include "non-perinatal" male controls, to parse out the prenatal effects of depres-sion and anxiety from normal variation, are needed4. Despite the prevalence and impact of paternal perinatal mood and anxiety disorders, family-focused programs that seek to address fathers' well-being are very few. Further, the absence of randomized controlled trials (RCTs) of tailored psychotherapy or pharmacotherapy is striking. The benefits of cognitive behaviour therapy (CBT)-based treatments, which have proven efficacy in maternal perinatal depression and anxiety, are unknown at this point in time. So too are the benefits of selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors, which have not been evaluated in RCTs in pregnant mothers on ethical grounds. Several models of care have been proposed for fathers. First, including fathers as supporting partners to mothers living with perinatal depression treated with in-dividual or group CBT. Second, using a whole family approach by engaging both partners in treatment concurrently (e.g., couples therapy). Third, providing exclusive treatment options for fathers with perinatal mental disorders (e.g., CBT). CBT delivered in a group setting or via the Internet may be viable options, as there is some evidence that they are associated with lower dropout rates in men. In a systematic review of interventions for paternal perinatal depression, six of the 14 trials found a significant but small reduction in depression scores, while the remaining eight reported no beneficial effects7. The interventions were all psychoeducationally oriented and, interestingly, none exclusively targeted paternal mental health. Instead, they addressed paternal well-being indirectly by focusing on the mother, infant or couple relationship. All this calls for targeted psychological and pharmacological intervention trials in fathers, including trials of transdiagnostic interventions for co-occurring mood, anxiety and substance use disorders, to establish what works. The urgency to provide interventions to men is underscored by findings of an association be-tween depression in fathers during the postnatal period and subsequent depression in daughters at age 18 years8. Perinatal mental illness cannot be optimally addressed if men are not included as active partners in the continuum of prenatal and postnatal care. Perinatal mental health services should routinely incorporate comprehensive assessment of paternal psychopathology. The time to act is now.