Dr Paul Sutcliffe: A blog for International Fathers' Mental Health Day
June 19th 2017
Mental health issues in fathers and fathers-to-be: future research and decision-making
About this blog
The purpose of this blog is to provide a research perspective on mental health issues in fathers and fathers-to-be. I will provide a brief overview of research being undertaken in this area. I will discuss some of the methods being used, telling you why research is important to advance our understanding and how it helps in future decision-making and changing policy. I am aiming to write this blog for the wider audience (you don’t need to be an academic to understand it!), so if you are a little curious to know what researchers do, then please stick with me. There may be times when I have to use more technical terms, but I will try to explain this clearly for you.
I will begin by giving you some information about myself and why I have become interested in this area. I currently work in Warwick Medical School as an Associate Professor. I’m deputy director for Warwick Evidence; which is one of the nine technology appraisal groups working on behalf of the National Institute for Health and Care Excellence (NICE). My research interests are in systematic reviewing and evidence synthesis (don’t worry if you don’t understand what these are, I’ll explain later). Warwick Evidence specialise in evaluating the clinical and cost effectiveness of health interventions (e.g., these might be drugs, psychological interventions or other types of technologies). I have a background in Experimental Psychology, but over the years my research interests have focussed more on how we use evidence that has already been undertaken, to evaluate health interventions and inform decision making (i.e. whether a drug should be used in the NHS). This information is important, as I recognise that many people are requesting that NICE updates the guideline for postnatal depression in women so that it includes fathers. I plan to discuss this later, explaining how NICE makes an evidence-based decision about which interventions to make mandatory on the NHS.
Now for the more interesting stuff! I have undertaken several large-scale pieces of work evaluating the evidence concerning postnatal depression in women. Along with colleagues in Sheffield and Nottingham, we’ve evaluated how effective group cognitive behavioural therapy is for postnatal depression in women and, more recently, looked at the prevention of postnatal depression in women. In both cases, fathers were not considered. It’s not that we felt fathers were irrelevant, rather, within any research we have to specify very clearly our inclusion and exclusion criteria (i.e. what is and what is not included). For those people who are not aware, there is a considerable amount of research that has been undertaken in women with postnatal depression and those at risk of developing postnatal depression. Therefore, to be able to look at the evidence, we had to be very clear who our population was, so the implications of our findings could then be proposed for that group of people.
I’m now in the process of generating a programme of research, with a specific focus on mental health issues in fathers and father-to-be. It’s not the purpose of this blog to tell you all about what I’m doing, but please feel free to contact me should you want to discuss this further with me.
Why am I interested in the area of mental health in fathers?
In a recent review, that I was involved in (led by Jane Morrell at the University of Nottingham), we investigated the clinical and cost effectiveness, and acceptability and safety, of antenatal and postnatal interventions for pregnant and postnatal women to prevent postnatal depression. We found a total of 178 papers that met our inclusion criteria (this is a huge number!). However, the results were very inconclusive. The most beneficial interventions seemed to be midwifery redesign postnatal care, person-centred approaches and cognitive behavioural therapy, interpersonal psychotherapy and education on preparing for parenting, as well as promoting parent infant interaction and peer support. So what does this mean for the prevention of postnatal depression in fathers? Well, what we also identified was that women valued seeing the same health worker, the involvement of their partners, and access to several visits from the midwife or health visitor trained in personal person centred or cognitive behavioural approaches, and these were all deemed to be extremely useful. It is essential that we learn from these findings and start channelling our resources into supporting both men and women with mental health issues.
What researchers do and why it is important
Before I go any further, I want to explain what do researchers do? If you’re anything like my parents you probably think that we just have an “easy life”, still behaving like students, drinking excessively and walking around with corduroy jackets on. While some of this may be true (not for me, of course), there are many different types of researchers. If we focus on researchers who work within a university department specialising in medicine or psychology or health, they are not necessarily from a medical background (like myself). You may be also picturing researchers in a laboratory wearing a white jacket and perspex glasses, who are looking intensely at test tubes. In fact, there are a large number of researchers who rarely need to step out of their offices or have direct contact with patients to undertake their research, this typifies the work of secondary researchers. This type of research gathers evidence from a variety of sources (e.g. online databases, Google scholar, books). This was what I was meaning by a “systematic review and evidence synthesis”. We gather all the available evidence and pool the evidence together, if they are using similar methods. We have researchers who specialise in systematic reviewing. They search, extract, appraise, synthesise, and evaluate evidence. They use rigourous (very thorough) and transparent (clear) methods.
Research can help shape society, it can change the way we do things and the way that we live our lives. In the context of mental health issues in fathers and fathers-to-be we may be interested in
investigating specific problems, concerns and issues using methods which can be repeated, this gives the study greater reliability. We might be interested in exploring how many fathers have specific problems and how long these problems last for. We might want to send out a postal questionnaire to contact a large number of people. In comparison, we may want to do more detailed evaluations of the impact of fathers with mental health issues, in which case, we may undertake interviews with fathers to explore their thoughts, feelings and difficulties.
So, what types of research have been undertaken in relation to the mental health of fathers and fathers-to-be? There has been research about the causes of the mental health difficulties in fathers. Researchers have looked at whether the mental health issues are triggered by situations (e.g., stressful events, financial difficulties, lifestyle and relationship changes). Other researchers have evaluated the impact on the relationship with their partner and baby.
There are some suggestions that treatment with psychological interventions like cognitive behavioural therapy, counselling and medication may be effective in treating some symptoms (e.g., depression). Relative to females, the transition of men to being fathers seems to have been relatively neglected. Pregnancy itself appears to have been identified as the highly stressful period for many men who were undertaking the transition to parenthood. Results suggest the most important changes appear to occur relatively early in pregnancy, when many men are ill-prepared for the impact of parenthood, especially in terms of a sexual relationship. The timings and trigger of stress in pregnancy is something that should be looked at further.
Prenatal and postnatal depression has been reported to affect approximately 10% of men across a whole range of studies. There is also reported to be a higher incidence of depression in the first 3- to 6-month period post-birth of the child. Depression in fathers has also been found to be closely linked to depression in their partners. What is also being considered is the impact of depression and other mental health issues in fathers on their offspring. Some researchers have reported an increased risk of later conduct problems, especially in boys, among fathers who were experiencing mental health issues. In addition, if we look at fathers who have long-term chronic depression postnatally, there have been suggestions of a higher risk of emotional and behavioural problems in their children. Further research needs to explore the mechanisms involved and identify ways in which we can reduce the potential risks of behavioural problems that may result in offspring.
A wide variety of measures have been used to screen for depression in women in the postnatal period, but there seems to be limited research investigating such measures in men. Three possible measures which may be used to screen fathers are the Edinburgh postnatal depression scale (EPDS), the Beck Depression Inventory and the Centre for Epidemiological Studies Depression Scale. However, there are no current programmes of routine screening of fathers for mental health issues in the pre-or postnatal period. More recently, there have been considerations of whether midwives or health visitors could be involved in identifying fathers or father-to-be who may be at risk of developing mental health issues following the birth of their child. Again, there are potential research opportunities here around the prevention of mental health issues.
It is important that researchers apply rigorous methods when attempting to evaluate the impact of mental health issues on fathers and fathers-to-be. We need to consider what the mental health issues are that need to be monitored and screened for, since the focus currently is on depression. We need to understand the characteristics and the symptoms that predict mental health issues in fathers (i.e., considering mental health issues such as obsessive-compulsive disorder and anxiety) and understand the impact of more severe mental health issues, and those men who may have had a predisposition or previous mental health history. We need to look at the relationships between fathers and mothers with mental health issues and whether combined treatment in a couple format may be helpful. Further discussion and evaluation around the impact of mental health issues in fathers on the family unit and the infant has been highlighted and needs further research.
So far, I’ve given you a flavour of what researchers do and just some of the areas of interest being studied in this area. In the next section, I want to talk about NICE and why they are important in decision-making, especially in the context of mental health issues in fathers and fathers-to-be.
What is NICE?
NICE was set up in 1999 by the Government to help decide which drugs and treatments should be made available on the NHS in England and Wales. It was initially established in an attempt to get rid of the postcode lottery, as some drugs and treatments were available only in certain parts of the country. It aims to ensure that all people have access to treatment and care wherever they live in the UK.
As I stated earlier, there has been some discussion around whether postnatal depression in fathers can be added on to the guideline of postnatal depression in women. The answer is that it would be difficult. Let me explain why I think this, by telling you how NICE decides which topic or condition to look at. The Department of Health in England and the NHS England decide which topic NICE will examine. NICE decisions are made by an independent committee. These always include patients, academics and researchers, and experts in the field. NICE makes a decision based on evidence, they look at the clinical and cost effectiveness of an intervention or treatment. Of particular consideration is the cost effectiveness, which considers the quality of life and the quantity of life. NICE don’t licence drugs or new devices, but once NICE makes a decision, that decision replaces any decisions that are made locally. Technology assessment groups, such as Warwick Evidence, examine the clinical and cost effectiveness of such interventions on behalf of NICE. Overall, NICE provide critical assessments of the evidence to make decisions. NICE use the best available evidence to develop recommendations that guide decisions in health public health and social care.
NICE guidelines make evidence-based recommendations on wide-ranging topics from preventing and managing specific conditions to planning broader services and interventions to improve the health of communities. So why is this important for mental health in fathers? Well, as yet postnatal depression in fathers isn’t currently recognised in the NICE guidelines. The Department of Health hasn’t proposed this as a topic for review. The Department of Health wouldn’t permit “fathers” to be added to the postnatal depression guideline for women. There are likely to be a number of steps which would need to be undertaken beforehand. There would need to be more primary research undertaken with fathers (e.g., studies assessing the effectiveness of preventative interventions or treatment on improving symptoms and quality of life with fathers) as at present there is likely to be limited evidence for NICE to be able to make any evidence-based recommendations for health and care in England. As growing evidence is reported in this field, it is hoped that Department of Health will then propose this topic to NICE, who will then request an evaluation of the evidence.
Well, if you got this point, thank you, this topic clearly is important to you. I hope it has given you an insight into what research is and some of the avenues that we might consider exploring, albeit, given the challenges ahead. In summary, I’ve tried to highlight the importance of research in moving this area forward. Unfortunately, it isn’t simply a case that we can make decisions about the treatment of mental health issues in fathers and fathers-to-be without evidence for its benefits. The other caveat which I haven’t alluded to is the issue of funding. Academics and researchers require funding to be able to undertake their proposed research. We need the Government to consider this a priority and funders to support research in this area. This is all going to take time. But, I am hopeful that NICE guidelines will be able to be generated to help health and social care professionals to prevent ill-health, promote and protect good health, improve the quality of care and services, and adapt and provide health and social care services for both mothers and fathers.
Thank you for reading this blog!
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