This article presents recent discussions that point to typical symptoms of paternal depression, which compromise the mental health of men and those around them. But first, we problematize, in just one time, the place of man in contemporary times and the construction of naturalistic models of masculine, which imprison him in a restrictive and non-creative way. Then, we review recent studies on paternal depression, which point to the complex aspects that involve the dynamics of the marital, parental and relational relationship. Finally, we discuss directions for public policy actions that privilege men's mental health, particularly during parenting.

Keywords: paternal depression, masculinity, contemporaneity, parental relationship, marital relationship

Global men's health has been a source of concern in recent years. Comparatively, studies point out the disadvantage of men in relation to women in terms of health, considering that the low demand for men for health services has its roots in the style of their socialization that attributes the caregiving role to women. Thus, the failure to take care of oneself in men can cost him his life, when he cares little about his physical and emotional health, which indicates a male position that does not need care. Following this line of reasoning, men who are at the moment of the life cycle in which they will become parents can run the risk of finding themselves without emotional reserves to cope with the turmoil of emotions that this period imposes on them. On this point, we will discuss a phenomenon recently recognized as a symptom also present in the male universe, depression during pregnancy and / or in the puerperium. The signs and symptoms surrounding this situation point to the high emotional burden that can occur in times of intense stress and do not match the ideal of masculinity of invulnerability.^1–4

Historicizing men's global health

The first studies on men's health focused, predominantly, on biological and epidemiological aspects. At that time, in the late 1970s in the United States, it was interesting to know health deficits and subjective aspects mattered little. Only after the 1990s did this discussion expand, considering, among other aspects, the more comprehensive health of men. What favored a closer look at the uniqueness of being healthy and being sick in the male universe.^5,6

Even today, we know the importance of producing public policies for the global health of men. However, few studies and projects in this regard have been carried out in a concrete way. In addition, we maintain the permanence of biological and epidemiological instances when we show studies that show that the majority of men tend to suffer from severe and chronic health conditions.^5,7,8 Otherwise, the specific literature considers it fundamental to reflect on masculinities, in their construction, historicity, style, relationships, existence, role and markedly cultural pattern. For men who identify with the ideal, hegemonic model of masculinity, self-care becomes a category absent from their practical life, not being one of their culturally expected attributes and functions.^9–12

In this story, man is expected to have a certain way of representing himself, valuing himself, acting in the world, both in relation to himself, to others, and in relation to the society in which he lives. In this scenario, we see the naturalization of the way of being a man that imprisons him in a male stereotype. It is observed in the literature and in clinical assistance to heteronormative families that the valorization of male virility is sustained in a society that reinforces the illusion of the heterosexual logic of the world and the domination power of men.^1,2,9 With this, common men are stuck to an ideal (virile, invulnerable and provider), which has been questioned by feminist and gay movements since the 1970s.⁴

These questions about the naturalist bases of male domination allowed to open a field of research and discussion around masculinity. As a result, another focus was gaining more defined outlines in the 1980s, deconstructing the male privilege, which plagues men in a universal and necessary conduct.^9,11

Although new studies on men's health are taking place, they are still insufficient and little acknowledged by the subjective aspects and the complex elements involved. For this reason, it is essential that we think about human health in a way that is more in tune with the complexity and uniqueness of human processes. For this, we need to recognize that in the life cycle of man there are different experiences that increase the meanings of being a man in the world in which we live.

Therefore, we will highlight the psychic phenomena pertinent to the pregnancy-puerperal period, the stage of the life cycle that interests us in this work. This is because, at this point in the life cycle, attention is usually focused on women, with men neglected in pre- and post-natal consultations. Its absence does not seem to be a source of concern or questioning on the part of the team that accompanies the pregnant woman's prenatal care. Once again, we do not advance in ways that consider the subjective production of the man-father, despite the significant changes that occur before and after the child's birth. This reality makes it difficult for the team to recognize and identify psychiatric disorders after paternal deliveries, especially the signs and symptoms of what I have been calling paternal depression, in view of the sensitive period that is that of pregnancy and the puerperium.^13–15

The malaise in fatherhood before its necessary construction

We know that during pregnancy and the puerperium, the man-father and the woman-mother face, among other things, a whirlwind of emotions and a series of psychological challenges, which can be experienced as exhausting and favor the outbreak of conflicts and difficulties. different personalities.^16,17 In some situations, these difficulties constitute a depressive condition, a phenomenon that has been investigated, at least with regard to mothers, with little attention being paid to men in this regard. After all, even in our culture we hardly recognize the emotional universe of man, especially in the pre, peri and post-natal period.¹⁸

In terms of paternal psychodynamics, we have studies that indicate that paternity is built from childhood as well as the desire to be a father. Therefore, even if the man is not actually pregnant, he participates in the pregnancy psychically, including summing up. We can observe that from the first semester, being more common in the third month of gestation, the man can manifest physical symptoms of unconscious and involuntary character, such as: nausea, gaining weight, losing appetite, having headaches, having palpitations, among other typical symptoms of pregnancy.^19,20 These psychosomatic phenomena were named by the British psychiatrist Trethowan as Couvade Syndrome.²¹

The studies by Trethowan and Conlon also highlighted that near the end of the pregnancy there was an increase in the occurrence of physical symptoms that could be accompanied by psychological symptoms, such as depression, tension, insomnia, irritability and even stuttering. Considering that the aspects of man's identity and self-image undergo changes during this period to incorporate the functions of the parental role, anxiety disorders are not uncommon.^20,21 Studies on parenting, on the other hand, relate the conscious and, mainly, unconscious aspects involved in the transition to fatherhood, such as empathy, identification, envy or competition with the mother.²²

This experience can provoke a diversity of feelings in the parents, influencing the way of relating to the pregnancy, the baby and the partner. At that time, conscious and unconscious processes are at stake that will influence the construction of parenting and the desire for the child.²² The dynamic and psycho-affective aspects present during the partner's gestation period reactivate their childhood conflicts in the man-father, making him question the position of son, and the transition from son to father. In view of the expectations generated to be a good father, it is not uncommon for a man to abandon his son because he is unable to exercise his fatherhood.^23,24

Probably, the demand on the part of men to assume an ideal of fatherhood has been reinforced by the growing social image of the participating father. In other words, it is expected that the contemporary father will not only be able to meet the ideal of masculinity, being the provider of the family, but, above all, be able to practice parenting, which involves the field of parental, physical and psychological care, and affective interactions. between parents and children,²² identifying and feeling love for the baby who has just arrived in the world as someone who has always been expected.

If the perinatal period favors a regression and an expression of its own, it does not guarantee the process of parenting the biological parents. At that time, a complex series of conscious and unconscious, subjective, cultural and social elements are at stake, which can be experienced in an extremely exhausting way, favoring the appearance of disorders, such as mood disorders.^16,25 For some men, the demand the woman, the baby and the social, psychological and family transformations expected in the parenting process can cause discomfort because they are experienced as excessive. However, we still know little about the man's experience in the transition to fatherhood, the lack of studies about it does not allow us to understand the phenomena involved in the process.^22,25–27 We understand that internal issues, and not only external ones, may favor depression, especially when there is no place to think that the father is rather a human being with issues pertinent to his existence.

The father does not exist

In this sense, there is no father, but there are parents, insofar as the subjective dynamics of each one bears the mark of their experiences and feelings since the child's pregnancy. This means that men are not born parents, they are produced in the family, social and cultural relational universe, as well as in the individual. But it will be in the meeting of the parent with his baby, that the chance of becoming a father-man can be realized. This is because the baby tends to be an active partner in the interaction with his parental caregivers, thus contributing to the construction of parenting.^22,28,29

In addition, studies show us that parental potentialities are favored when there is no external interference, enabling interactions and affective care. By exercising the role of father in his own way, autonomy and a unique way of being a father-man are achieved, which can vary with time and with the styles of interaction with the child. In contact with his abilities, the father feels more secure and confident in the practice of parenting.

Countless works by sociologists and anthropologists show the different ways of being a father and mother in different cultural and social realities. The cultural and social elements help in the production of the parental function, giving meaning to the daily mishaps of the parent-child bond. On the other hand, this is also a singular and individual process that involves affection, care, personal family history.²² In contemporary society, the knowledge of specialists is privileged, and parents are not encouraged, in most cases, to show what they know or to learn from experience. It is even believed that women would be more skilled at instinctual knowledge, which has been criticized by different authors. This social and cultural disauthorization of men's ability to care for their children has, in practice, a series of consequences.

It is possible to follow different realities in which men complain, or are accommodated, for being prevented from practicing parenting in their own way in the daily care of the child; judicially claim, when divorced or separated, privileges common to mothers (follow the routine of the day, have more than a weekend, participate in decisions about the child's life, among other topics); the feeling on the part of some men that they are not able to care, among others. For these men, still present in our society, despite the diverse movements in favor of an open discussion on the possibilities of being a father, it is important to have a media space that indicates pluripaternality, emphasizing how paternity and its different forms are on the agenda contemporaneity. Even if at this point in the life cycle, turbulence and crisis are present, there is a possibility of advancing in ways that consider the subjective production of the father-man and his ability to mobilize new ways of being a father.^22,30

The paradox in public policies and mental health in cases of paternal depression

As can be seen above, it is still difficult to recognize the complexity of the process of paternal parenting, which makes it difficult to investigate physical and emotional symptoms, which may suggest the diagnosis of paternal depression, in parents in the context of a pregnancy or in the postpartum period. The symptoms of paternal depression can be observed during pregnancy as well as after the birth of the child. Therefore, it is important to understand the pregnancy-puerperal period as part of a family transition process, which can cause different repercussions in the affective universe of man, as in his fantasies and in his mental world. This moment of family changes and rearrangements is favorable to paternal depression. This is because, during this period, the man may resent his partner, feeling jealous and angry at the woman's relationship with the baby. Usually, when the baby becomes unwanted, it causes guilt and shame in the man, who depresses due to the anguish generated.^{13,14,23–27,31}

Despite the literature pointing to the emotional impact and complexity of the pregnancy-puerperal period, the experiences, doubts and feelings of men are still not addressed in prenatal and post-natal care, with the focus on women remaining. Even Mental Health services and Public Policies do not seem to articulate with the institutions and professionals in the perinatal area a bridge of conversation that will increase the investigation of symptoms specific to men in the pregnancy-puerperal period, which compromise male mental health. , reverberating to the marital relationship and the parent-child relationship (a).^32,33 Perhaps this field of male perinatal mental health remains obscured due to the idea that professional support would make the man-father feel in an uncomfortable, crazy place. In addition, the myth persists that the man is the one who helps, he is the provider, and that he does not need to be helped, making it difficult to seek appropriate treatment. Authorizing the father a place where he can express his questions is fundamental and indispensable, after all, the presence of a quiet and safer father is important both in the mother's relationship with the baby, as he could provide necessary support for both, as in the relationship him with the baby and his partner.^1,2,9

Prenatal and postpartum depression in men is not an area to be given much attention. From studies on depression in general, it is known that, if one member of the couple is depressed, the chances of the other also succumbing; it is also argued that a woman's mood tends to accompany a man's mood. Therefore, it may be that, in some cases of postpartum depression, the new father was already depressed before birth and that his depression precipitated the mother's illness. Studies show that depression in the father can lead to behavioral problems in the baby. According to Paul Ramchandani, from the University of Oxford, author of the pioneering study that relates paternal depression and impaired child development, boys are the most affected. There is evidence that when the mother is depressed, the baby turns to the father for compensation. This affective overload may be one of the explanations for paternal depression, but not the only one, after all, we also know that there are many triggering factors of this disorder.¹⁴

Susan Ayers, director of the Center for Maternal and Child Health Research at City University, London, during the presentation “Perinatal Mental Health - the experience of women and health professionals” in 2019, warned that the data has shown that the prevalence symptoms of postpartum depression is equivalent between men and women. Therefore, an integration between professionals of different specialties (gynecologist-obstetricians, pediatricians, family and community doctors, clinicians, psychiatrists, psychologists) should be sought, from the prenatal period, to monitor not only the mother-child couple. child, but also the couple, man and son, in view of the relevant prevalence of paternal depression, as well as its association with other problems.^30–32

The absence of Public Policies and Mental Health services dedicated to the man-father is worrying when we show the negative impact on his life, the couple and the father-son relationship. Notably, some symptoms may already indicate some clues for health professionals regarding the depressive condition in the man-father, such as: crying less; having an attack of unexplained tiredness; psychosomatic phenomena; lack of appetite, sleep disorders (even if the baby sleeps well); feeling like a bad father; anxiety and nervousness, loss of libido; end of interest (or pleasure) in daily activities for a minimum period of two weeks; missing appointments; present inappropriate behaviors and suffer more or less serious accidents on the way to motherhood. In many cases, men resort to escape mechanisms, dedicating a good part of their time to work or extra-marital relationships, which implies their removal from the family, that is, from the mother-baby dyad.^13,23,34

In addition to the experiences common to the time of perinatality, in assisting the man-father it is of great relevance that attention is given to the social support network of the man-father, it is fundamental to sustain the psychic changes experienced with the birth of a baby and all the transformations inherent to the moment of the life cycle.

We also highlight our concern with this theme due to studies that point out that paternal postpartum psychiatric disorders indicate significant prevalence (in Brazil they vary between 11.93 and 25.4% 5) and directly impact on paternal support to mother and baby during the first postpartum year, compromising the mental health of men, women and babies.^10,27,35

Another point that must be emphasized is the diagnosis, which is sometimes hampered due to psychosomatic complaints that may suggest only organic problems. These organic symptoms have the most common causes: women with postpartum depression, stress, concern for the family's support, feeling excluded or rejected by their partner, difficulty in dealing with ambivalent feelings, such as wanting to protect and care for the baby and the woman and, at the same time, wish to occupy the space that she has always had in her life. When the professional can identify and recognize the symptoms, articulating them with the experience lived subjectively by the man, it is possible to refer the patient to a therapeutic approach that helps him to alleviate the suffering that is not only of the father but of everyone in the family.

In view of the lack of assistance to the man-father throughout pregnancy and the puerperium, we recommend that incentive actions be promoted so that more men are present at perinatal consultations. We suggest, therefore, that in the process of parenting, which intensifies during pregnancy and the puerperium, health professionals should pay attention to the emotional universe of men. It is not uncommon to need referrals for psychological and / or psychiatric monitoring throughout the prenatal period and in the first year of life of the child. With the recognition of the father's depressive state, the possibility of helping the father and his family opens up, especially during pregnancy and the postpartum period of his partner.^19,26,36

As we have seen throughout this work, in assistance we still have one of the biggest challenges, which is the identification by health professionals of symptoms and, consequently, the appropriate provision of care. This is due, on the one hand, to the signs that are often silent and atypical, when compared to the signs of women with postpartum depression, and may even present baby-blues without being noticed.

We concluded in this investigation that it is much more difficult to diagnose paternal depression than maternal depression. One of the many reasons is that men resisted seeking help, making it even more difficult to endure the new situation. In addition, society continues to identify depression as a female problem, not something likely to happen to men. The denial of depression in the male universe makes it difficult to understand the effects of paternal depression on men themselves.^6,15,22 Therefore, it is essential that the assistance provided by the man-father is assisted by a team that is able to identify symptoms and to approach the father in an appropriate and careful way, referring him, if necessary.^37-43

It is important to emphasize the need for more in-depth studies on the behavioral and emotional changes of men since they became aware of pregnancy until the baby's second year. We hope that advances in the methodological sense will increase our understanding of paternal depression, helping us to indicate better preventive clinical conduct.

None.

The authors declared no conflict of interest.

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