Strange tales of lactating men or male pregnancy pains crop up in the news from time to time, despite the fact that men cannot get pregnant. Does that mean men are also susceptible to bouts with prenatal and postpartum depression?

Previous research has found rates of depression in new dads that range from 1 percent to 25 percent, but a new meta-analysis, published May 19 in JAMA, Journal of the American Medical Association, assessed 43 studies of a total of more than 28,000 fathers and found that an average of 10.4 percent suffered from depression sometime between the first trimester of their partner's pregnancy and the child's first birthday.

Rates of paternal depression were highest three to six months after birth (25.6 percent) and in the U.S. (14.1 percent versus the international rate of 8.2 percent). All of these numbers are considerably higher than the annual rate for adult male depression, which is 4.8 percent (but lower than the rate for maternal prenatal and postpartum depression, which is estimated to be 23.8 percent).

"This suggests that paternal prenatal and postpartum depression represents a significant public health concern," concluded the authors of the new paper.

Many moms get what is known as the baby blues, a passing sadness in the first few days after the birth of their child. But postpartum depression in both mothers and fathers is a condition that lasts longer, and "it may be very problematic for families and child outcomes," says James Paulson of the Department of Pediatrics at Eastern Virginia Medical School, the lead author of the meta-analysis. Extreme examples of parental depression can lead to suicide or to harm or neglect of the baby, but even mild to moderate depression in fathers has been shown to have lasting negative effects on their children for years to come.

Difficult diagnosis
Postpartum depression in moms has become a more widely discussed—and diagnosed—issue in recent years, but finding fathers who are going through something similar has proven difficult. Diagnostic questionnaires often focus on questions about sadness and other states that men typically are less likely to acknowledge. Some researchers have advocated to change the vocabulary to include issues such as irritability, emotional withdrawal and detachment, which can also be symptoms of depression in men, Paulson says.

Additionally, "there's a general cultural myth that men don't get depressed," says Will Courtenay, a psychotherapist and researcher in Oakland, Calif. who is completing research on paternal postpartum depression in collaboration with Harvard's Center for Men at McLean Hospital. "Because of that cultural myth, men oftentimes think they shouldn't get depressed, and when they are depressed they try to hide it."

Many new parents endure a host of symptoms often associated with depression (such as fatigue, change in appetite or anxiety), even if they have a clean bill of mental health. As a parent of an infant, "you don’t have time to eat a normal diet, you don't have time to get eight hours of sleep," Paulson notes. So "trying to parse out fatigue" and other normal indicators of depression can be tricky, he says. But for people who have clear cases of clinical depression, there are cues beyond typical parenting troubles, such as persistent detachment, feeling hopeless or worthless, or thoughts of death.

Finally, doctors and pediatricians usually see new fathers less often than they do new mothers, who are most frequently the parent bringing a baby in for appointments during the first year of life. Even though screening for depression in mothers is far from perfect, it is much easier to do given their more regular contact with the health care system, Paulson noted at a May 18 press briefing hosted by JAMA in New York.

Paternal biology
As the childbearers, women have been the primary focus for studies of physiological and psychological changes during and after pregnancy. But more recent literature has begun to uncover changes in dads as well. A few studies have found hormonal changes in men about to become fathers and those who have just had a child, Paulson notes, though he is quick to add that none have yet linked these changes specifically to depression. Many of these shifts, however, mirror those occurring during the same period in women's bodies, such as increases in estrogen and prolactin, Courtenay says.

The sleep deprivation that comes along with being a new parent can alter neurochemical balances in the brain, making some people with underlying risk factors more vulnerable to depression. "It's kind of a double whammy," Courtenay says. "All these hormonal changes and neurochemical changes in the brain due to sleep deprivation can wreak havoc on a man."

In part due to the paucity of research on paternal prenatal and postpartum depression, experts are still sketchy on the risk factors for fathers. A personal history of depression puts both mothers and fathers at a higher risk, as does a sick baby, financial strain or relationship problems. Add to that list the changing expectations pushing dads to become more involved parents, says Courtenay, and many new fathers are left feeling overwhelmed and at greater risk for anxiety and depressive symptoms.

In a study Courtenay is currently undertaking, initial data from some 1,500 fathers have shown that other risk factors include an unexpected pregnancy or unhappiness with the baby's gender.

Downsides of depressed dads
Like mothers who are depressed, fathers who suffer from depression can have negative impacts on their children's development years down the road.

"When Dad is depressed, Dad tends to interact less with the child and bonds less with the child," Paulson notes. He coauthored a study that found fathers with depression were less likely to read to their children, and those children were more likely to have relatively poor language skills.

A study of more than 10,000 children in the U.K., published in 2005 in The Lancet, found that "depression in fathers during the postnatal period was associated with adverse emotional and behavioral outcomes in children aged 3.5 years." This correlation was seen even when the researchers controlled for maternal depression, the authors, led by Paul Ramchandani of the University of Oxford, concluded.

Another study, published in 2008 in The Journal of Child Psychology and Psychiatry, found that children whose fathers had been depressed during their early infancy were more likely to have behavioral problems by the time they were school age—a finding Paulson calls "very alarming." The longitudinal study, also led by Ramchandani, found that kids whose fathers had been depressed in both the prenatal stage and the first month of infancy "had the highest risk of subsequent psychopathology." And the effect was especially strong in boys who had had depressed fathers.

Depression in dads also seems to correlate with depression in mothers. Although the relationship is not one-to-one, having a partner with this sort of depression seems to increase an individual's likelihood of having it, too. This should prompt clinicians to assess the partners of parents with depression, Paulson says. Currently, however, he notes, "we don't know what direction that influence moves."

Addressing dads' depression
Although he has been studying paternal postpartum depression for several years, Paulson was surprised to find a big difference between rates in the U.S. and those from studies based elsewhere. U.S. fathers had nearly twice the rate of paternal prenatal and postpartum depression, leading Paulson and his coauthor, Sharnail Bazemore, also of Eastern Virginia Medical School, to suggest further research on the "varying social norms and postpartum work practices cross-nationally."

As in mothers, postpartum depression in fathers seems to spike between three and six months after the birth of a child. Paulson speculates that this might have to do with the typical three-month term for maternity leave in the U.S., after which many mothers return to work, shifting responsibilities within the family. It is also an age at which children start exhibiting more challenging behavior, he notes.

Paulson recommends investigating treatment that focuses on whole families, addressing depression "as a family problem, not an individual problem."

Courtenay proposes ways to help prevent paternal—and maternal—depression from becoming a problem in the first place. With a growing checklist of risk factors, he says, the best thing to do is address any of them "before the baby comes along." If there is a history of depression, be prepared for a relapse and have plans in place for seeking treatment quickly. If there is strife in the relationship between the parents, seek counseling or other help before or during pregnancy. Or if a father-to-be is starting to feel anxious about his new role and responsibilities, he should enroll in a parenting class. "Putting that stuff in order beforehand" can help keep disruptive parental depression at bay, Courtenay notes.

The first step, researchers seem to agree, is improving awareness that paternal prenatal and postpartum depression exists and is likely to affect about one in 10 fathers. With more than 10,000 children being born each day in the U.S. and more than 14 percent of U.S. fathers experiencing some depression during pregnancy or the first year of infancy, "that's not an insignificant number" of men who will get depressed, Courtenay says.

But experts are making headway in informing the medical community—and the general public. Paulson notes that most of the studies he found on paternal depression have been published in the past several years, and other indicators are looking up, as well. Not too long ago, typing "paternal depression" into Google would return the suggestion: "did you mean maternal depression," he noted at the press conference today. The same search now quickly turns up more than 18,000 results.