A prospective study of postnatal depressive symptoms and associated risk factors in first-time fathers

Journal of Affective Disorders 249 (2019) 371–377

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Research paper

A prospective study of postnatal depressive symptoms and associated risk factors in first-time fathers

T

Deborah Da Costaa,b, , Coraline Danielic, Michal Abrahamowiczc, Kaberi Dasguptaa,b, Maida Sewitcha,b, Ilka Lowensteynb, Phyllis Zelkowitzd ⁎

a

Department of Medicine, McGill University, Canada Division of Clinical Epidemiology, McGill University Health Centre – Research Institute, Canada c Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada d Lady Davis Institute, Department of Psychiatry, Jewish General Hospital and McGill University, Canada b

ARTICLE INFO

ABSTRACT

Keywords: Postnatal paternal depression Prevalence Risk factors

Background: Recent studies show that paternal depression negatively impacts children's behavioral and emotional development. This study determined the prevalence of depressed mood in first-time fathers at 2 and 6 months postpartum and identified associated risk factors. Methods: A prospective cohort study with 622 men who completed sociodemographic and psychosocial questionnaires during their partner's third trimester of pregnancy. Fathers completed measures again at 2 and 6 months postpartum and partners completed the depressed mood measure at all three timepoints. A cutoff of ≥10 for the Edinburgh Postnatal Depression Scale identified depressed mood status. Results: The prevalence of depressive symptoms in fathers was 13.76% at 2 months and 13.60% at 6 months postpartum. Men who were depressed during their partner's pregnancy were 7 times more likely to be depressed at 2 months postpartum. Depressed mood status at both the antenatal and 2 month postpartum assessment was associated with increased risk of depressed mood at 6 months postpartum. Older age, poor sleep quality at study entry, worse couple adjustment, having a partner experiencing antenatal depressive symptoms and elevated parental stress were associated with depressive symptoms at 2 months postpartum. Poor sleep quality, financial stress and a decline in couple adjustment were independently associated to depressive symptoms at 6 months postpartum. Limitations: This sample was fairly well-educated and predominately middle-class. Depressive symptoms were assessed using a self-report questionnaire. Conclusions: 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.

1. Introduction There is mounting evidence that an important number of expectant and new fathers experience depressive symptoms during the perinatal period (Cameron et al., 2016; Paulson and Bazemore, 2010). Paternal psychological distress is related to unhealthy lifestyle behaviors (i.e. greater use of alcohol and marijuana) (Sipsma et al., 2016; Spector, 2006), maternal postpartum depression (Paulson and Bazemore, 2010), and poorer quality of paternal-infant interactions (Lamb, 2004; Ramchandani et al., 2008; Sethna et al., 2015). Paternal depression during the perinatal period has been shown to negatively affect the child's behavioral, emotional, cognitive and physical development

(Letourneau et al., 2012b; Sethna et al., 2015; Sweeney and MacBeth, 2016). Two meta-analyses have estimated the rate of depression in expectant and new fathers to be approximately 8.4–10.4% (Cameron et al., 2016; Paulson and Bazemore, 2010). In the earlier meta-analysis, the rate of depression during the transition to parenthood was highest at 3–6 months postpartum (25.6%) (Paulson and Bazemore, 2010). In contrast, in the most recent meta-analysis the rate was relatively stable from pregnancy to 12 months postpartum, however more studies with multiple time-points across the perinatal period are needed to more accurately estimate prevalence rates at specific periods during the transition to parenthood (Cameron et al., 2016). The prevalence rate of

⁎ Corresponding author at: Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, 5252 de Maisonneuve Blvd. W., Office 3E.10, Montréal, QC H4A 3S5, Canada. E-mail address: [email protected] (D. Da Costa).

https://doi.org/10.1016/j.jad.2019.02.033 Received 25 September 2018; Received in revised form 11 January 2019; Accepted 11 February 2019 Available online 11 February 2019 0165-0327/ © 2019 Published by Elsevier B.V.

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paternal depression varies widely across studies due to heterogeneity of measurement methods, population assessed, publication year and study location (Cameron et al., 2016; Paulson and Bazemore, 2010). The rate of paternal depression is highest in North America and the lowest in Europe and Australia. In the most recent meta-analysis (Cameron et al., 2016), the North American studies included 20 from the United States, and only two small-scale studies from Canada (de Montigny et al., 2013a; Hall and Long, 2007). A larger Canadian study with multiple time points is needed to better ascertain the prevalence of paternal depression in the postpartum period and determine if the rates are indeed stable across the perinatal period as suggested by recent findings (Cameron et al., 2016). Sociodemographic factors including paternal age (younger or older), unemployment, and lower education and household income have been associated with paternal postpartum depressive symptoms (Cameron et al., 2016; Edward et al., 2014; Underwood et al., 2017). However, these associations have not always been consistent, partly because of insufficient power and precision of the analyses (Cameron et al., 2016). Among psychosocial factors, higher paternal antenatal depressive symptoms, lower social support, poorer adjustment in the couple relationship, having a depressed partner and higher parenting stress have been associated with paternal postpartum depression (Cameron et al., 2016; Edward et al., 2014; Nishimura et al., 2015; Paulson and Bazemore, 2010; Ramchandani et al., 2008; Vismara et al., 2016; Wee et al., 2011; Zhang et al., 2016). More recently, sleep difficulties have also been associated to paternal depression during the partner's pregnancy (Da Costa et al., 2015; Juulia Paavonen et al., 2017). However, these factors have not always been examined together making it difficult to determine if they are independent risk factors for paternal postpartum depressive symptoms. In addition, in many studies psychosocial risk factors were assessed only in the postpartum period (de Montigny et al., 2013b; Nishimura et al., 2015; Vismara et al., 2016; Zhang et al., 2016). Yet, identifying risk factors during the partner's pregnancy would help to target antenatal screening and interventions to reduce the risk of paternal postpartum depressive symptoms. To address these issues, we aimed to determine the prevalence of depressive symptoms in first-time fathers at 2 and 6 months postpartum, and identify independent risk factors, in a large Canadian cohort. For the latter aim, we explored the temporal relationships of putative sociodemographic and psychosocial risk factors with paternal depressive symptoms in the postpartum. Specifically, we distinguished between cross-sectional associations of paternal depressive symptoms at 2 and 6 months postpartum with sociodemographic and psychosocial factors measured at the same time, and longitudinal analyses of associations with their antenatal values. Finally, we also explored if and how changes in these factors from the antenatal to the postpartum period may be associated with paternal postpartum depressive symptoms at 2 and 6 months postpartum.

completed the questionnaires in English, while 20.3% completed the French versions of the questionnaires. The study was approved by the McGill University Faculty of Medicine Institutional Review Board and by the ethics boards of the participating hospitals. 2.2. Measures Paternal depression was assessed with the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987), a widely used 10-item scale, originally developed and validated for new mothers, and validated in fathers (Edmondson et al., 2010; Matthey et al., 2001). Items inquire about mood in the past seven days and are rated on a four point scale, with a total score ranging from 0 to 30. In men, a cut-off of EPDS ≥ 10 has been shown to be optimal for detecting minor or major depression, with a 71.4% sensitivity and 93.8% specificity (Matthey et al., 2001). Mothers also completed the EPDS at each assessment. Good internal consistency has been reported for the original English version of the EPDS for both men and women (Cronbach's α = 0.81 and 0.87, respectively) (Cox et al., 1987; Matthey et al., 2001). The French Canadian version of the EPDS used in this study has previously been shown to have good psychometrics properties (Cronbach's α = 0.80) (Verreault et al., 2014). In the present study, Cronbach's alpha at each assessment point ranged from 0.82 to 0.84 and 0.79 to 0.6 for the English and French versions, respectively. The Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., 1989) assesses sleep quality and disturbances in the past month. It includes 19 items, generating 7 component scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. A global score conveying the number and severity of sleep problems is obtained by summing the seven component scores. The global score has a possible range of 0 (no sleep difficulty) to 21 (severe sleep difficulties). The scale has good psychometric properties (Cronbach's α = 0.83), with a global score >5 yielding a diagnostic sensitivity of 89.6% and specificity of 86.5% in differentiating good and poor sleepers (Buysse et al., 1989). In the present study, Cronbach's alpha at each assessment point ranged from 0.58 to 0.65 and 0.51 to 0.65 for the English and French versions, respectively. These internal consistency values are similar to values found in other studies with non-clinical samples (Mollayeva et al., 2016). The Dyadic Adjustment Scale (DAS) (Spanier, 1976) measured men's level of adjustment in their couple relationship. It yields a total score (ranging from 0 to 151), with higher scores indicating a better couple relationship. The DAS has been widely used in studies of marital quality and parental adjustment (Ramchandani et al., 2011; Weinfield et al., 2009). High internal consistency for the original English scale has been demonstrated (Cronbach's α = 0.91 alpha coefficient) (Spanier and Thompson, 1982). The French Canadian version of this instrument has shown adequate psychometric properties (Baillargeon et al., 1986). In the present study, Cronbach's alpha at each assessment point ranged from 0.90 to 0.92 and 0.91 to 0.93 for the English and French versions, respectively. The Modified MOS Social Support Survey was used to assess social support (Czajkowski et al., 1997). This 7-item shortened version of the original scale (Sherbourne and Stewart, 1991) assesses perceived support from one's social network related to emotional, tangible and affectionate domains. It yields a total score ranging from 7 to 35, with higher scores indicating higher perceived social support. Good internal consistency has been reported for the original version (English version, 0.88, French version, 0.91) (Anderson et al., 2005; Czajkowski et al., 1997; Sherbourne and Stewart, 1991). Cronbach's alpha at each assessment point in this study ranged from 0.90 to 0.92 and 0.89 to 0.92 for the English and French versions, respectively. Financial stress was measured with four items developed by Kim et al. (2003) assessing satisfaction with one's present financial situation, income adequacy, debt, and saving and investment. Responses

2. Methods 2.1. Participants and procedure Couples in the second or third trimester of pregnancy were recruited by research staff or through study flyers in the waiting rooms at obstetric/gynecology clinics associated with three teaching hospitals in the Montreal area and at local prenatal classes. Couples were at least 18 years of age, functionally fluent in French or English, married or cohabiting and expecting their first child. In the third trimester (28–36 weeks) expectant parents who had indicated an interest in participating were each separately e-mailed a prompt to the password secured website to access the electronic consent form and questionnaires through Fluid Surveys. Participants had one week to complete them and reminder phone calls were used to encourage completion and answer questions. The same procedure was used at the 2 and 6 month postpartum follow-ups. At study entry 496/622 (79.7%) expectant fathers 372

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are coded on a 4-point Likert-type scale, from 4 = agree to 1 = disagree, and summed, with a possible total score range of 4–16. A higher total score indicates greater financial stress. An acceptable level of reliability (Cronbach alpha = 0.79) has been demonstrated for this measure (Kim and Garman, 2003). Cronbach's alpha at each assessment point in this study for this measure ranged from 0.74 to 0.80 for the English version and 0.80 to 0.83 for the French versions. The Parenting Stress Scale (PSS) (Berry and Jones, 1995) was included in both postpartum surveys to measure father's subjective feelings of strain, difficulties and dissatisfactions as a parent. This 18-item scale is appropriate for both fathers and mothers and for parents of children with or without clinical problems. Possible total scores range from 18 to 90, with higher scores indicating greater parental stress. Adequate psychometric properties have been shown for this scale (Cronbach alpha = 0.83) (Berry and Jones, 1995). In the present study, Chronbach's alpha at both timepoints was 0.87 for the English version, and 0.81 and 0.87 for the French version. Sociodemographics, medical history, smoking behavior, and current health status were collected using a self-report questionnaire developed for this study.

Table 1 Baseline characteristics of the sample completing the 2 months postpartum follow-up (n = 487). Age, mean (SD), y Ethnicity – white, no (%) Marital status, no (%) Married Co-habitating Time with partner, mean (SD), y Education - University degree, no (%) Household incomea Employment status- working, no (%) Smokers PSQI-global score, mean (SD) Social support, mean (SD) Dyadic adjustment scale, mean (SD) Financial stress, mean (SD) EPDS, mean (SD)

34.27 (5.01) 366 (75.46) 408 (83.78) 79 (16.22) 6.40 (3.50) 347 (71.40) 5.81 (1.93) 446 (91.58) 98 (20.1) 4.61 (2.67) 29.95 (4.69) 123.77 (12.79) 8.38 (3.03) 4.99 (3.86)

Abbreviations: PSQI, Pitsburgh Sleep Quality Index; EPDS, Edinburgh Postnatal Depression Scale. a Income scale 1–8; eg. 5 = $61,000-$80,000; 6 = $81,000-$100,000.

non-white ethnic origin. Nearly 72% (n = 347) completed university and 71.55% (n = 337) had a yearly family income above $60,000.

2.3. Statistical analysis Descriptive statistics included means, standard deviations and frequencies. Two different sets of multivariable logistic regression models were employed to examine characteristics associated with postpartum depressive symptoms, separately at 2 and 6 months. In all models the binary dependent variable represented postpartum depressive symptoms (EPDS ≥ 10) at either 2 months or 6 months postpartum and, to respect the critical ratio of outcomes to variables in the model, independent variables were selected using forward selection procedure, with a liberal p < 0.15 criterion for entry, to reduce the risk of residual confounding. The first set of models assessed only risk factors measured concurrently with the postpartum depressive symptoms assessment. The second set explored the associations, mutually adjusted, of (a) psychosocial factors assessed antenatally and (b) changes in those factors from baseline to the postpartum assessment time of interest, with postpartum depressive symptoms at that time. These associations were also adjusted for depressed mood in the previous timepoint(s), and for parenting stress at 2 months postpartum. Finally, changes in parenting stress from 2 to 6 months postpartum were included in the model predicting depressive symptoms at 6 months. All analyses were limited to complete cases, at the respective followup assessments. Strength of the association was assessed by adjusted Odds Ratios (OR), with 95% confidence intervals (CI), and its statistical significance was defined as p < 0.05 for the 2-tailed model-based Wald test. Statistical analyses were performed using R version 3.1.1.

3.1. Prevalence of depressive symptoms The prevalence of paternal depressive symptoms at 2 months postpartum was 13.76% (67/487) (CI:10.70,16.82) and 13.60% (51/375) (CI: 10.13,17.07) at 6 months. Among men reporting depressive symptoms at 2 months postpartum, 40.30% (n = 27/67) also experienced depressive symptoms during the antenatal assessment, and among those with depressive symptoms at 6 months postpartum, 24% (n = 12/51) experienced depressive symptoms at both the antenatal and 2 months postpartum assessments. 3.2. Concurrent risk factors for postpartum depressive symptoms The risk of paternal depressive symptoms at 2 months postpartum increased for men who concurrently had worse sleep quality (OR,1.25; CI:1.10,1.42), poorer couple relationship adjustment (OR,0.97; CI:0.94,0.99), and higher parenting stress (OR,1.07; CI:1.02,1.11) (Table 2). Unemployment (OR,3.75; CI:1.00,13.72), poorer sleep quality (OR,1.37; CI:1.16,1.65), lower social support (OR,0.92; CI:0.84,1.00), poorer couple relationship adjustment (OR,0.95, CI:0.92,0.98) and higher financial stress (OR,1.21, CI:1.04,1.42), assessed concurrently were all significantly associated with paternal depressive symptoms at 6 months postpartum (Table 3). Concurrent partner depressive symptoms were marginally associated with paternal depressive symptoms at 2 months, but not at 6 months.

3. Results

Table 2 Multiple logistic regression evaluating the concurrent associations of sociodemographic and psychosocial variables with depressive symptoms in fathers at 2 months postpartum.

Of the 1176 men who agreed to learn more about this study, 622 completed the on-line questionnaires during their partner's third trimester (52.9%), 487/622 (78.3%) and 375/622 (60.3%) completed the questionnaires at 2 and 6 months postpartum, respectively. Men who withdrew at the 2 month postpartum follow-up were more likely have a non-white ethnicity (chi-square = 8.3, p = 0.004), lower income (t = −2.1, p = 0.037), and reported lower social support (t = −2.5, p = 0.012) during the antenatal assessment. Participants who withdrew at the 6 month follow-up had higher EPDS scores at 2 months postpartum (t = −2.5, p = 0.012). There were no differences between men who completed vs. those who withdrew from the postpartum assessments on any other sociodemographic and psychosocial variables. Sample characteristics at study entry for the fathers completing the 2 months postpartum assessment are shown in Table 1. The mean age for the fathers was 34.27 years (SD = 5.01) and 24.54% (n = 119) had

Factors

OR (95% CI)a

p-value

Intercept Age Sleep quality Dyadic adjustment Parenting stress Partner EPDS score

0.01 1.06 1.25 0.97 1.07 1.07

0.06 0.06 <0.01 0.01 <0.01 0.06

[0.00,1.14] [1.00,1.14] [1.10,1.42] [0.94,0.99] [1.02,1.11] [1.00,1.15]

Abbreviations: Postpartum depression symptoms defined as Edinburgh Postnatal Depression Scale score 10 or higher; OR odds ratio; CI confidence interval; EPDS Edinburgh Postnatal Depression Scale. a Adjusted for all other variables in the model. 373

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Table 3 Multiple logistic regression evaluating the concurrent associations of sociodemographic and psychosocial variables with depressive symptoms in fathers at 6 months postpartum. a

Factors

OR (95% CI)

Intercept Ethnicity White Other Work status Employed Unemployed Parental leave Sleep quality Social support Dyadic adjustment Financial stress Parenting stress

3.04 [0.02,502.66]

0.66

reference 2.42 [0.88,6.55]

0.08

reference 3.75 [1.00,13.72] 2.25 [0.37,10.40] 1.37 [1.16,1.65] 0.92 [0.84,1.00] 0.95 [0.92,0.98] 1.21 [1.04,1.42] 1.04 [0.99,1.09]

0.04 0.33 <0.01 0.05 <0.01 0.01 0.15

Table 5 Prospective associations between psychosocial variables with depressive symptoms in fathers at 6 months postpartum (T2). Factors

p-value

Work status Employed, T0 Unemployed, T0 Sleep quality, T0 Social support, T0 Financial stress, T0 Δ Financial stress Δ Sleep quality Δ Couple adjustment Δ Partner EPDS Depressed statusb Not depressed at T0 & T1 Depressed T0 only Depressed T1 only Depressed T0 & T1

Abbreviations: Postpartum depression symptoms defined as Edinburgh Postpartum Depression Scale score 10 or higher; OR odds ratio; CI confidence interval. a Adjusted for all other variables in the model.

Older age (OR,1.08; CI:1.01,1.16), poorer sleep quality during their partner's pregnancy (OR,1.34; CI:1.14,1.58), and having a partner with elevated depressive symptoms during pregnancy (OR,1.11; CI:1.00,1.22) were independently associated with higher paternal depressive symptom risk at 2 months, together with higher concurrent parenting stress (OR,1.05; CI:1.00,1.09) (Table 4). Declines in both sleep quality (OR,1.36; CI:1.17,1.59) and couple adjustment (OR,0.94; CI:0.90,0.97), from pregnancy to 2 months postpartum were associated with paternal depressive symptoms at that time. Men experiencing depressive symptoms during the antenatal assessment were 7 times (OR, 7.64; CI:2.97,20.33) more likely to report depressive symptoms at 2 months postpartum. Poorer sleep quality (OR,1.29; CI:1.04,1.61) and higher financial stress (OR,1.37; CI:1.15,1.66) at the antenatal assessment were risk factors for paternal depressive symptoms at 6 months postpartum (Table 5). Both an increase in financial stress (OR 1.26, CI:1.01,1.60) and a decline in couple relationship adjustment (OR 0.93, CI:0.89,0.97), relative to the antenatal assessment, were associated with higher risk of depressive symptoms at 6 months postpartum.

p-value

Age Sleep quality, T0 Partner EPDS score, T0 Parenting stress, T1 Δ Sleep quality Δ Couple adjustment Δ Partner EPDS ADS Not depressed Depressed

1.08 1.34 1.11 1.05 1.36 0.94 1.07

(1.01,1.16) (1.14,1.58) (1.00,1.22) (1.00, 1.09) (1.17,1.59) (0.90,0.97) (0.98,1.17)

0.02 <0.01 0.04 0.03 <0.01 <0.01 0.12

reference 7.64 (2.97,20.33)

<0.01

reference 3.38 (0.80,13.46) 1.29 (1.04,1.61) 0.92 (0.83,1.01) 1.37 (1.15,1.66) 1.26 (1.01, 1.60) 1.15 (0.95,1.39) 0.93 (0.89,0.97) 1.10 (0.97,1.24)

0.09 0.02 0.09 <0.01 0.05 0.15 <0.01 0.12

reference 2.89 (0.59,12.45) 6.71 (1.56,28.49) 5.41 (1.12,27.52)

0.17 0.01 0.04

Fathers reporting depressive symptoms at 2 months postpartum but not during their partner's pregnancy were 7 times more likely to be depressed at 6 months postpartum (OR, 6.71, CI:1.56,28.49) compared to men without elevated depressive symptoms at either earlier timepoint. Men with elevated depressive symptoms during the antenatal assessment and at 2 months postpartum were 5 times (OR 5.41, CI:1.12,27.52) more likely to be experiencing depressive symptoms at 6 months compared to men who did not report elevated depressive symptoms at either previous assessments. 4. Discussion This is one of the first Canadian studies to report on the prevalence and the antenatal determinants of depressive symptoms at 2 and 6 months postpartum in a sample of first-time father. We found that 13.8% and 13.6% of first-time fathers experienced depressive symptoms at 2 and 6 months after their infant's birth. This pattern is consistent with other emerging studies on postpartum depressive symptoms in fathers, which suggest that the rate of depressive symptoms in men during the transition to parenthood is relatively stable in the 12 months postpartum (Cameron et al., 2016; Vismara et al., 2016). These findings are vitally important because of the known negative impact of paternal depression upon infant, child and adolescent development (Sweeney and MacBeth, 2016). Our estimate of prevalence of paternal postpartum depressive symptoms is consistent with two earlier meta-analyses, that reported a 13–14% prevalence in North American countries (Cameron et al., 2016; Paulson and Bazemore, 2010), and is much higher than the 2.8% (95% CI 2.3,3.2) past year prevalence rate found for depression among all adult men in the Canadian Community Health Study—Mental Health (Patten et al., 2015). Prior studies observing higher prevalence rates of paternal depressive symptoms during the perinatal period in North America compared to other continents were primarily based on studies from the United States, our Canadian estimates are equally high (Cameron et al., 2016). This high rate is unlikely to reflect differences in parental leave policies, because the province of Quebec, where this study was conducted, offers parental leave benefits comparable to other countries with lower prevalence of paternal postpartum depression.

Table 4 Prospective associations between sociodemographic and psychosocial variables with depressive symptoms in fathers at 2 months postpartum (T1). OR (95% CI)a

p-value

Abbreviations: PDS postpartum depression symptoms defined as Edinburgh Postnatal Depression Scale score 10 or higher; T0 baseline; T1 2 months postpartum; T2 6 months postpartum; OR odds ratio; CI confidence interval; EPDS Edinburgh Postnatal Depression Scale; Change scores (Δ) in this model reflect changes between baseline (during partner's third trimester of pregnancy) and 6 months postpartum. a Adjusted for all other variables in the model. b Paternal depression status defined as Edinburgh Postnatal Depression Scale score 10 or higher.

3.3. Longitudinal determinants of postpartum depressive symptoms

Factors

OR (95% CI)a

Abbreviations: PDS postpartum depression symptoms defined as Edinburgh Postnatal Depression Scale score 10 or higher; ADS paternal antenatal depression symptoms defined as Edinburgh Postnatal Depression Scale score 10 or higher; T0 baseline; T1 2 months postpartum; OR odds ratio; CI confidence interval; EPDS Edinburgh Postnatal Depression Scale; Change scores (Δ) in this model reflect changes between baseline (during partner's third trimester of pregnancy) and 2 months postpartum. a Adjusted for all other variables in the model. 374

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Literature on both maternal depression (Halbreich and Karkun, 2006) and, more recently paternal depression (Cameron et al., 2016), suggests that the variability in perinatal depressive symptom rates across countries may be related to cross-cultural variables, reporting style, perceptions of mental health and stigma, differences in socioeconomic environments and/or biological vulnerability factors. In the present study, fathers’ experiencing antenatal depressive symptoms had a 7-fold increased risk of depressive symptoms at 2 months postpartum, consistent with earlier findings in both mothers (Milgrom et al., 2008; Norhayati et al., 2015) and fathers (Escriba-Aguir and Artazcoz, 2011; Koh et al., 2014; Ngai and Ngu, 2015; Suto et al., 2016). Our findings also extend previous studies by showing that fathers who exhibited depressive symptoms at 2 months postpartum, were 5–7 times more likely to be depressed at 6 months postpartum, even if they were not depressed antenatally. These findings point to the importance of including fathers when assessing antenatal and postnatal depressive symptoms in mothers. Offering prompt targeted interventions to expectant parents and new parents with elevated risk of depression is vital to alleviate depressive symptoms during pregnancy and prevent the persistence of symptoms in the postpartum period. Studies to track depressive symptoms in expectant fathers earlier in pregnancy are needed to better identify the optimal time to offer interventions to reduce perinatal symptom severity. Our multivariable analyses also identified other risk factors, independent of antenatal depressive symptoms and earlier postpartum depressive symptoms, to help guide screening and intervention development tailored to expectant fathers. Among the sociodemographic variables examined, older age was associated with depressive symptoms at 2 months postpartum. Paternal age has been inconsistently examined in relation to postpartum depressive symptoms (Cameron et al., 2016; Paulson and Bazemore, 2010), and previous results were ambiguous. While our finding is consistent with some studies (Deater-Deckard et al., 1998; Edward et al., 2014), others reported increased risk for younger fathers (Ballard et al., 1994; Bielawska-Batorowicz and Kossakowska-Petrycka, 2006). The World Health Organization estimates that unemployment increases the risk of mental disorders by more than three-fold (WHO International Consortium in Psychiatric Epidemiology, 2000), consistent with our findings that fathers unemployed at 6 months postpartum were almost four times more likely to be experiencing concurrent depressive symptoms. Others have also shown a relationship between unemployment and depression in fathers (Bronte-Tinkew et al., 2007; Hoard and Anderson, 2004; Underwood et al., 2017), with its importance remaining strong regardless of family's overall socioeconomic status (Rosenthal et al., 2013). Both antenatal and concurrent poor sleep quality was associated to depressive symptoms at 2 and 6 months postpartum, even after adjusting for antenatal depressive symptoms. We have previously reported poor sleep during the partner's pregnancy to be associated with antepartum depressive symptoms in this sample of first-time fathers (Da Costa et al., 2015). We now extend these findings to suggest that sleep disturbances appear to be a negative prognostic factor for the development or persistence of depression in men during the entire perinatal period. In non-psychiatric non-postpartum populations and in women during the perinatal period, associations have been found between earlier poor sleep quality/quantity and later depression (Baglioni et al., 2011; Bei et al., 2010; Okun et al., 2011; Skouteris et al., 2009; Wu et al., 2014). In women, this relationship may be mediated by decreased restorative benefits of sleep resulting in diminished coping with postpartum demands (Bei et al., 2010; Tham et al., 2016). A similar pathway may link sleep quality to postpartum depressive symptoms in fathers. Our findings suggest that screening for, and addressing, sleep difficulties in men during the transition to parenthood may help prevent the development or persistence of depressive symptoms. Paternal depressive symptoms at 6 months postpartum were associated with the concurrent perceived level of social support. In women greater social support during pregnancy is consistently reported to be

protective against postpartum depressive symptoms (Kim et al., 2014; Robertson et al., 2004; Xie et al., 2009). While men are expected to be a key source of support for women during the perinatal period, support for fathers can also facilitate the transition to parenthood. Our findings suggest that prevention programs should include strategies to mobilize support from one's partner, family and friends. Further studies are needed to better understand which dimensions of social support (e.g. informational, emotional, tangible) are most beneficial to men during the transition to parenthood. Consistent with other studies (Boyce et al., 2007; de Montigny et al., 2013a; Escriba-Aguir and Artazcoz, 2011; Escribè-Agüir et al., 2008; Gawlik et al., 2014; Roubinov et al., 2014; Wee et al., 2011), both poorer concurrent adjustment in the couple relationship and its decline from baseline were independently associated with elevated depressive symptoms at 2 and 6 months postpartum. Given that at least half of couples may report a decline in couple adjustment following childbirth (Kluwer, 2010), it may be particularly important to include adaptive couple strategies, such as division of labor, couple communication, and co-parenting, as part of prenatal preparation to prevent distress in the couple relationship after childbirth. Both antenatal and concurrent financial strain, as well as its increase after childbirth, were all associated with risk of depressive symptoms at 6 months postpartum. Limited financial resources for providing and raising an infant increases the stress placed on new fathers. A small community-based study, reported a relationship between economic stress and elevated psychological distress in men whose partner's were depressed (Zelkowitz and Milet, 1997). Economic worries assessed during the partner's pregnancy have been previously associated with paternal depressive symptoms at 3 months postpartum (Bergstrom, 2013). Our findings suggest that financial hardship likely predates paternal depression during the transition to parenthood and, thus, requires addressing in targeted prevention efforts. Parenting stress in the present study was concurrently associated with depressive symptoms at 2 months postpartum, consistent with postpartum studies in mothers (Horowitz and Goodman, 2004; Misri et al., 2006; Thomason et al., 2014). The fact that the association between concurrent parenting stress and PDS was non-significant at 6 months highlights the time-dependent nature of the associations between potential stressors and depressive symptoms at different postpartum timepoints. While maternal postpartum depressive symptoms have been shown to influence depressive symptoms in fathers (Cameron et al., 2016), findings related to the relationship between maternal antenatal depressive symptoms and paternal depressive symptoms are mixed (Cameron et al., 2016; Paulson et al., 2016). We found a marginal association between maternal depressive symptoms and paternal depressive symptoms in the multivariable model examining concurrent determinants of depressive symptoms at 2 months postpartum. Only a few studies of antenatal risk factors for paternal depressive symptoms have included maternal antenatal depressive symptoms. Our results for antenatal predictors of depressive symptoms at 2 months postpartum are consistent with others showing an association between maternal antenatal depression and postpartum depressive symptoms in fathers (Areias et al., 1996; Ramchandani et al., 2008). Further prospective studies over the postpartum year with a larger sample size to ensure sufficient power are needed to further examine the relationship between partner depressive status and paternal depression. Given the pervasive nature of paternal depression, its adverse impact on parental and child-related outcomes, and the fact that we identified several other risk factors for paternal depressive symptoms, independent of maternal depression symptoms during pregnancy, expectant and new fathers should be screened for depression during the perinatal period even when their partner is not experiencing depressive symptoms. The present study has several limitations. The 53% response rate at study entry was similar to other studies with mothers during the transition to parenthood (Banti et al., 2011; Redshaw and Henderson, 2013; 375

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Acknowledgments

Yelland et al., 2010), but could affect the accuracy of the prevalence estimates. Moreover, 40% of the initial participants who did not complete the postpartum assessments were more likely to be of non-white ethnicity, have lower socioeconomic status and lower social support, which might have induced some selection biases. This sample was fairly well-educated and predominately middle-class, limiting generalizability. Studies targeting more socially vulnerable populations are needed, as are perhaps the inclusion of incentives such as a small gift card as a token appreciation following questionnaire completion at each timepoint to increase response rate and minimize loss to follow-up (Edwards et al., 2009). Whereas diagnostic clinical interviews remain the gold standard for identifying clinical depression (Eaton et al., 2007), we assessed depressive symptoms by self-report. However, the EPDS is the most widely used tool to assess depressive symptoms in parents during the perinatal period and was validated in expectant and new fathers (Edmondson et al., 2010; Matthey et al., 2001). Finally, although this study assessed a broad range of risk factors, including some (e.g. sleep) rarely investigated in relation to paternal depressive symptoms in the postpartum, other variables associated to postpartum depressive symptoms in parents (de Montigny et al., 2013a; Hildingsson et al., 2014; Underwood et al., 2017; Wosu et al., 2015) were not assessed (e.g. history of depression, pregnancy and birth related anxiety, prior perinatal loss, trauma history) and require further study. Despite these limitations, this study used a prospective design, had a large sample size, carefully assessed temporal relationships between risk factors and outcomes, and evaluated a broader range of both concurrent and antenatal risk factors in a population of first-time Canadian fathers. Our findings indicate that a significant number of new fathers experience elevated depressive symptoms during the transition to parenthood. This is important because father's depression during the perinatal period has been associated with adverse child development outcomes, independently of maternal psychological adjustment. Most of the antenatal risk factors identified were consistent predictors of paternal depressive symptoms at 2 and 6 months postpartum, suggesting a vital need for prenatal screening and support for expectant parents at risk of postpartum depressive symptoms. Indeed, there is little resistance from mothers and fathers to screening but rather an interest in depression screening by expectant parents (Letourneau et al., 2007, 2012a). Pregnancy may be a “teachable moment” for educating and preparing men at risk for mental health difficulties. Strategies to promote better sleep, mobilize social support and strengthen the couple relationship may be important to address in innovative (i.e., mobile and web-delivered) interventions tailored to new fathers at risk for depression during the perinatal period.

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Author declaration All authors have seen and approved the final manuscript. Contributors DDC is the principal investigator of the study and PZ is the coprincipal investigator. DDC and PZ designed the study protocol, CD and MA designed statistical analysis plan and CD undertook the statistical analyses. DDC drafted the manuscript, and all authors read, revised and approved the final manuscript. Funding This study was funded by the Canadian Institutes of Health Research (247035). Declaration of interest None. 376

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