No Hormones – No problem? Male PND Myths dispelled

When I started working on this site I, somewhat naively, thought that it would be greeted with open arms as a positive offering to men who are struggling with depression after becoming a new dad. But, as with anything in this life, things are a little more complicated…

For reasons that will become apparent, the first draft of this article was a ranting, passive-aggressive self-justification piece aimed at one particular misinformed fellow who implied that I was out to “mislead” men. It wasn’t fit for publication. It did however set the scene for addressing some of the misconceptions and myths which surround the phenomenon of Male post-natal (or post-partum) depression. I hope you like it.

The story began when my wife sent me a text saying that Male post-natal depression was going to be a topic on The Wright Stuff show. Optimistically and without thinking about it too much, I sent a tweet to the show suggesting that they check out the site:

Twitter Wright Stuff Male PND

This was the first response…

Twitter Wright Stuff Male PND 2 blurred

“Misleading men?” (Note: This is where the first draft of the article explored in depth the anger and other unpleasant emotions that I experienced in relation to our tweeter’s over-confident assertion that I am out to mislead. Whilst it would have made a good academic paper for a psychodynamic therapy training course, it definitely wouldn’t do much to further the cause of Male PND, so I’ll spare you the details (and expletives)).

I read on…

Twitter Wright Stuff Male PND 3 blurred

This is one of the first things that we hear people say when they compare female PND to male – “Isn’t it caused by hormones, and if men arent’t actually carrying the baby, then how could it apply to them?” Except, only 10% to 15% of women develop post-natal depression. If hormonal changes were the cause of PND, and all women experience the same hormonal changes, then we would expect all women to develop PND. They don’t. Therefore, it is widely accepted that there are other factors involved.

The following list (accredited to Beyond Blue) details many, but not all, of the other factors which can contribute to the development of post-natal depression. As we can see, many of these factors can effect men as well as women – no biochemical changes necessary!

• Personal or family history of mental health problems or current mental health problems
• Pregnancy, labour or delivery complications
• Perinatal loss, e.g., miscarriage, stillbirth or termination
• Current or past history of physical, psychological, or sexual abuse
• Anxious or perfectionist personality
• Lack of support from family and friends
• Stressful life events (e.g., moving house)
• Continuing lack of sleep or rest
• Unplanned pregnancy
• Having multiples (e.g. twins or triplets)
• Severe baby blues after the birth
• Premature baby
• Difficulties with breastfeeding
• A baby that is difficult to settle
• Partner experiencing perinatal depression or anxiety

So, to really labour my point, and with reference to the original tweet – Post Natal Depression isn’t something that just “effects women biochemically.” This is an unhelpful myth that perpetuates the notion that depression is all in the head, rather than it being the consequence of multiple interacting biological, psychological and social factors, many of which can be acted upon (with appropriate support) to reduce distress.

I’m sorry that our tweeter feels that men will be ridiculed for “latching on” to a biochemical explanation for their depression symptoms. I don’t know if it’s true that men will be ridiculed or not, but there is evidence to suggest that men do also experience changes in hormones throughout the pregnancy and post-natal period. Testosterone, Oestrogen, Cortisol, Vasopressin and Prolactin have all been identified as being hormones which change in Men during the period, and changes in each have all been suggested to underlie a part the experience of Post-natal depression symptoms in men. Personally, I’m not the worlds biggest advocate of a purely biochemical (sometimes called the bio-medical model) explanation for depression, instead believing it be an interplay between biopsychosocial factors, but with reference to the tweeters concerns about ridicule, if someone has a physical issue which is beyond their control (i.e., hormonal changes) then surely they are less likely to be ridiculed for something than if it was something that was potentially within their control (i.e., a skill deficit or difficulty coping). Just my view.

Next…

Twitter Wright Stuff Male PND 4 blurred

I’ve heard this one before too.

Except, the UK guidelines for the treatment of Post-natal Depression and for the treatment of Depression are essentially the same. Here are the NICE guidelines for the treatment of post-natal depression:

Managing a new episode in the postnatal period

How should I manage a new episode of depression in the postnatal period?

• For women in the postnatal period who are not breastfeeding, manage as for depression in the general population. See the CKS topic on Depression.

For women in the postnatal period who are breastfeeding:

• Involve the woman, and her family where appropriate, in all decisions about treatment (see Making decisions about treatment).

For a breastfeeding woman who develops mild or moderate depression during the postnatal period, and does not have a previous history of depression, consider:

• Self-help strategies, non-directive counselling delivered at home, or brief psychological treatment (see psychological treatments).

For a breastfeeding woman who develops mild depression during the postnatal period and a has a history of severe depression, consider psychological treatments.

• If she declines, or does not respond to psychological treatment, consider seeking specialist advice on the use of antidepressants.

For a breastfeeding woman who develops moderate depression during the postnatal period and has a history of depression, consider:

• Structured psychological therapy specifically for depression (cognitive behavioural therapy [CBT] or interpersonal therapy [IPT]).

• Antidepressant treatment (if the woman has expressed a preference for it and is aware of the risks associated with antidepressant use during breastfeeding). Consider seeking specialist advice.

• Combination treatment (psychological treatment plus an antidepressant) if there is no response, or a limited response, to psychological or drug treatment alone, provided the woman understands the risks associated with the use of antidepressants during breastfeeding. Consider seeking specialist advice.

For a breastfeeding woman who develops severe depression during the postnatal period, consider:
• Structured psychological therapy specifically for depression (CBT or IPT).

• Antidepressant treatment (if the woman has expressed a preference for it and is aware of the risks associated with antidepressant use during breastfeeding). Consider seeking specialist advice.

• Combination treatment (psychological treatment plus an antidepressant) if there is no response, or a limited response to psychological or drug treatment alone, provided the woman understands the risks associated with the use of antidepressants during breastfeeding.

• If the woman requires psychological treatment, ensure that she is seen promptly (ideally, within 1 month of initial assessment, and no longer than 3 months afterwards). If prompt access to psychological therapies is not available, see the section on delivering psychological treatments.

We can see here that psychological treatment (CBT or IPT) is the preferred treatment for Post-Natal Depression in women. Antidepressant medication is considered secondarily.

And here are the NICE treatment guidelines for depression:

For people with mild depression or subthreshold depressive symptoms who request an intervention, consider a period of active monitoring, and:

• Provide information about the nature and course of depression.
• Arrange follow up, normally within 2 weeks (consider contacting the person if they do not attend follow-up appointments).

For people with persistent subthreshold depressive symptoms or mild-to-moderate depression:

• Consider a psychological intervention. This is accessed by referral or self-referral to IAPT (Improving Access to Psychological Therapies). Following assessment, the following interventions may be offered:
• One or more low-intensity psychological interventions or group-based cognitive behavioural therapy (CBT) for people who decline this intervention.
• A group-based peer support programme, either alone or in combination with the above, for people with a chronic physical health problem.

Avoid the routine use of antidepressants, but consider this for people with:
• A history of moderate or severe depression.
• Subthreshold depressive symptoms that have persisted for a long period (typically at least 2 years).
• Mild depression that is complicating the care of a chronic physical health problem.

For people with moderate or severe depression — offer an antidepressant and a high-intensity psychological intervention. Psychological interventions are accessed by referral or self-referral to IAPT. The type of intervention offered will depend on the severity of depression and the presence or absence of a chronic health problem.

We can see that psychological therapies are the preferred treatment, with medication being considered in more severe cases. The treatment for both is the same.

If I was to treat a woman for post-natal depression with CBT, I would be looking to identify patterns of avoidance and reduced activity and support her to modify these. I would teach her how to problem solve current and potential stressors and I would also be interested in understanding how she thinks about herself and her situation, support her to re-evaluate unhelpful thought content and disrupt unhelpful thinking processes such as worry and rumination. But if I was treating a man… Guess what? I would do exactly the same. There may be differences in context and content (just as there are between all individuals who enter therapy) but the actual treatment would be the same.

There is also a good point to be made here to further challenge the biochemical explanation for PND mentioned earlier. NICE recommends psychotherapies as the preferred treatment for depression and post-natal depression, before the introduction of antidepressant medication. This is based upon multiple studies which show that CBT or IPT perform just as well as, or better than, antidepressants in research trials on depression treatment, with fewer side effects. Now, when a therapist sits down with a client, they don’t say, “right, let’s get your hormonal imbalance sorted out.” They instead say, “what would you like to change?” meaning, “how can we change things about you, your relationships, your environment, etc to get you feeling better?” We don’t treat hormones, we treat people. Leaning too much upon a purely biochemical model can leave individuals feeling passive, hopeless and resigned to their sadness, rather than empowering them to take even the smallest action to remedy their situation. Taking action leads to change and the opportunity for recovery.

I’m sure there are many more myths and beliefs that people hold about Male Post-Natal depression and I’m happy to tackle them all if it means that more men will be prepared to get help when they need to. Keep ’em coming.

George Maxwell Therapist 250px

George Maxwell is an Accredited Cognitive Behavioural Therapist and director of Access CBT UK.
He specialises in the treatment of Male depression in the post-natal period but also has extensive skills in working with PTSD, Anxiety disorders, OCD and Panic. If you would like to arrange individual therapy with him (either face to face or via Skype), or would like to receive information and updates relating to New Dad Depression then feel free to contact him at enquiries@accesscbt.co.uk or follow on twitter @newdad_depressn.

 

Disclaimer: Depression in New Dads takes no liability for consequences of using materials on this site. In the event of crisis, a suitably trained mental health practitioner should be consulted.

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