Design and setting

This qualitative study was conducted between January 2021 and July 2021 as part of a PhD study by the first author (CD) under the supervision of the second author (VS) at Anglia Ruskin University, England. It is based on a constructivist paradigm, which means that participants were considered in their cultural, individual and psychological dimensions (Pilarska 2021) such as their home and work environments and their father and partner roles.

Recruitment and participants

The study was advertised on social media with the help of advocates and charities in the field of fathers’ mental health, on the university intranet, through a press release and through a local radio interview. Potential participants were invited to contact the first author.

Interested participants were recruited if they self-identified as having experienced postnatal depression, since postnatal is not routinely screened for or diagnosed. To be included in the study, participants had to be the biological father of the child and have been living with the child’s mother at the time of the birth. This ensured a level of homogeneity in the sample, enabling participants’ experiences to be described in depth (Palinkas et al 2015) and collectively.

Eight fathers participated in the study, a sample size that is consistent with previous qualitative research in fathers with postnatal depression (Schuppan et al 2019, Pedersen et al 2021) and is considered sufficient to produce an adequate volume of data in interview-based studies (Vasileiou et al 2018).

Data collection

Data were collected through individual semi-structured interviews, which took place online using teleconferencing software. This was due to restrictions arising from the coronavirus disease 2019 (COVID-19) pandemic but had the advantage of enabling fathers to take part from anywhere in the UK and at a convenient time for them (Archibald et al 2019). The interview schedule was designed to help participants describe their personal experiences of help-seeking and support for postnatal depression while enabling the researchers to answer the research question. The interviews lasted between 27 minutes and 114 minutes. They were conducted, audio-recorded and transcribed manually by the first author.

Data analysis

Interpretative phenomenological analysis was chosen as the conceptual framework for data analysis. It involves ‘exploring, describing, interpreting and situating the means by which our participants make sense of their experiences’ (Smith et al 2009). It is particularly suited to emotional or challenging topics (Smith and Osborn 2015).

The first author examined the interview transcripts in detail, extracting and coding quotes from different participants expressing similar ideas. The codes were examined individually, then grouped based on similarity of meaning. Narrative accounts were written for each participant, facilitating the first author’s familiarisation with, and interpretation of, the data. The first author considered the similarities and differences between the individual accounts to make claims about participants’ experiences overall.

The first author, a female registered health visitor, kept a reflexive diary during transcription and data analysis to minimise researcher bias and ensure rigour (Johnson et al 2020). To ensure that gendered preconceptions did not influence the analysis, the data coding was checked and validated by the second author, a male professor of psychology, who examined the first author’s interpretations of the data to check whether they were representative of participants’ experiences.

Ethical considerations

Ethical approval was sought and granted by Anglia Ruskin University’s ethics panel. Approval from a research ethics committee was not required since participants were not recruited through healthcare settings.

After contacting the first author, potential participants were sent a participant information sheet. If they decided to take part they were asked to provide written consent by email. Before their interview they were asked to reiterate their consent verbally and given the opportunity to ask questions. They were assured that they would be free to interrupt the interview and withdraw from the study at any time without consequences. To check that participants were not experiencing or receiving care for severe depression and therefore safeguard them, they were asked to complete the Patient Health Questionnaire-9 (Kroenke et al 2001).

Confidentiality was protected throughout the study. The transcripts were anonymised and identifying details, such as names of people and places, were removed before data analysis. Participants were given pseudonyms and their identity was known only to the first author. When writing up the findings, further characteristics that could enable others to identify participants were omitted. The study was conducted alongside a study into fathers’ lived experiences of postnatal depression (Davenport and Swami 2023). The participants were the same in both studies but the chosen pseudonyms are different to ensure details about participants cannot be linked between the two studies.

Not recognising postnatal depression

At the time, participants did not recognise or understand that they were experiencing postnatal depression and were reluctant to share their experiences with others. Initially, participants considered their symptoms of postnatal depression to be ‘normal’ and to reflect the tiredness of new parenthood. However, participants described reaching a point when they realised they were experiencing a serious mental health issue or distress:

‘I wasn’t enjoying it. That’s when it just… I’d gone from not enjoying it to wishing it’d never happened and that was the catalyst that was the real point of yeah, that’s pretty bad to feel like that, that’s when it was the worst.’ (Victor)

Coping strategies that participants would have used before becoming fathers, such as reading or exercising, often became unfeasible after the birth of the child. As a result, they resorted to managing their distress through self-reliance and avoidance:

‘Dealing with it as best as I could individually.’ (Xander)

‘Ride it out, you know it’ll get better.’ (Samuel)

Coping with postnatal depression was described in terms of surviving; for example, Zack described how he would just try to get through one day at a time. However, these strategies did not help participants with their feelings of depression. Participants avoided discussing their feelings – Richard tended to bottle them up, William would never have thought about discussing them and Paul thought that doing so would make him feel uncomfortable.

Fatherhood expectations restricting postnatal depression disclosure

Participants’ internalised perceptions of the social expectations of fatherhood restricted the sharing of their experiences. Participants all described feeling inadequate in their parenting role; for example, Richard expressed the feeling that his children had not got the best of him. These feelings also arose from participants’ perception of having to play a certain role in the family unit, notably as the breadwinner:

‘Dad can’t ask for help, you’re supposed to be the pillar of the family, you’re supposed to be the breadwinner.’ (Zack)

For most participants, the idea of being asked about their depression was exposing and something that they sought to avoid:

‘You found outlets and ways of avoiding having those conversations with people.’ (Xander)

Participants also described a need to minimise or avoid disclosing their symptoms because they perceived their partner’s needs as greater than their own:

‘Seeing what she went through to give birth to him, you know, a bit of mental anguish on my part didn’t really seem particularly worthy of attention.’ (Samuel)

‘If I feel like this, then God knows what his mum feels like, so it would always be to downplay what was going on.’ (Paul)

Despite participants’ attempts to protect their partner by avoiding disclosure, partners recognised that participants were experiencing postnatal depression. Some participants eventually spoke to their partners about their depression but rarely fully disclosed their experiences to them:

‘The less she knew, the less she’d worry.’ (Thomas)

Partners also strongly influenced participants’ formal help-seeking, encouraging them to see their GP.

Disappointment at the medicalised response to help-seeking

Five participants were immediately offered antidepressants when they visited their GP. They were all disappointed by this and initially refused treatment. They considered antidepressants inappropriate, with concerns that treatment would change their personality or that they were being offered antidepressants because of a lack of other types of support. Some participants stated they would have preferred, or had expected, to be offered talking therapy:

‘They just kept saying right, antidepressants, or whatever it is, just surrounding as an umbrella but they weren’t targeting the problem.’ (Richard)

‘I was worrying that taking the pills would sort of take the edge off that and make me a different person altogether.’ (William)

‘[The GP] said, “To be honest I don’t think there’s that much out there for depressed dads, nothing I’m aware of anyway”.’ (Samuel)

‘I went in with the expectation that I was probably going to be referred to a counsellor.’ (Paul)

Five participants eventually received talking therapy.

Five participants took antidepressants, often as a result of pressure from their partner, who had expected medicines to be the mainstay of treatment offered by the GP:

‘My wife was very much expecting me to get medicated immediately… She was also disappointed that I didn’t stick with the medication.’ (Xander)

In terms of the care provided by their GP, four participants found it helpful to be diagnosed with postnatal depression or depression. For example, Samuel found that the diagnosis helped him to explain and accept his symptoms:

‘He’d given me that label… not that it was a label I wanted to proudly display, but I guess it just helps you internalise, accept it… I was relieved it was official.’ (Samuel)

Health visitors as a feared profession which excludes fathers

Participants recalled health visitors coming to their home but thought that they were there to support mothers, not fathers. Participants felt excluded and some of their interactions with health visitors were negative:

‘I didn’t know they were there to help me as well.’ (Zack)

‘The moment [my partner] said she was starting to buckle, a whole system seemed to leap into place, the health visitor was coming round… but even they never spoke to me, no one ever spoke to me.’ (William)

‘[The health visitor] was just not inclusive of dad and didn’t really value or listen to my opinion.’ (Richard)

‘I remember twice they came on Saturday, because I was there, and both times I was asked to leave the room.’ (Paul)

Participants commonly linked health visitors with safeguarding practices and feared that disclosing that they were experiencing symptoms of depression would create a risk of the child being removed from the family:

‘If I did say I was struggling, then it becomes a very different issue and then what happens? Like, is she going to ring social services and is she going to take my child away?’ (Xander)

‘You don’t know, if you turn round to this person [and tell them] look, we’re struggling… if it’s gonna trigger anything.’ (Victor)

Needing communication, validation and a safe space to talk

When seeking support from healthcare professionals, participants tended to minimise their distress. One participant used physical pain as the reason to consult his GP. Xander communicated that he needed help but used humour to do so:

‘It was in a jokey way that I said it, it was like “I wish someone would ask me that question, ha ha ha!”.’ (Xander)

Disclosing their symptoms of depression to healthcare professionals made participants feel vulnerable and the environment in which it would happen became significant:

‘I guess I just wasn’t quite sure what to expect so the idea of being quite open and vulnerable to someone I’ve not met, on a regular basis, especially when I was struggling enough about things emotionally anyway, it was quite difficult to comprehend that.’ (Thomas)

Most participants wanted to share how they felt but needed a safe space to do so. For participants, feeling safe to disclose their symptoms meant feeling included and listened to, knowing what would happen, not being rushed and being afforded a private space away from their partner.

Talking therapy was viewed as offering safety and increased participants’ awareness and understanding of the mental health issues they were experiencing:

‘It made me more aware that there was something wrong.’ (William)

‘I felt that I understood that it was to do with my relationship with [my son].’ (Paul)

Limitations of talking therapy included lengthy waiting times, a limited number of sessions and a lack of availability – which led some participants to use private services.

Limitations

The richness of data and the depth of analysis enabled the authors to highlight the nuances and complexity of fathers’ help-seeking for postnatal depression. However, the lack of diversity in the sample limits the findings’ application to other contexts of fatherhood, such as non-biological fatherhood, racialised minority fatherhood or gay, bisexual or transgender fatherhood. Because of the recruitment methods, people who do not use social media, lack digital skills or lack access to the internet could have been excluded from participating. Another potential limitation arose from the fact that the interviewer was a female health visitor, which potentially limited the extent to which participants disclosed their experiences.