Elsevier

Journal of Affective Disorders

Volume 190, 15 January 2016, Pages 675-686
Journal of Affective Disorders

Prevalence and course of anxiety disorders (and symptom levels) in men across the perinatal period: A systematic review

https://doi.org/10.1016/j.jad.2015.09.063Get rights and content

Abstract

Background

Men's experiences of anxiety within the perinatal period can adversely impact themselves, their partner and infant. However, we know little about the prevalence and course of men's anxiety across the perinatal period. The current review is one of the first to systematically review the published literature.

Methods

Five databases (PubMed, PsycINFO, Cochrane, SCOPUS, and Web of Science) were searched to identify relevant papers published prior to April 2015. The literature search identified articles with data for expectant fathers (prenatal period) and/or fathers of an infant aged between 0 and 1 (postnatal period). The following data were extracted: (a) anxiety disorder prevalence (diagnostic clinical interviews), (b) ‘high’ anxiety symptom prevalence (above thresholds/cut-points on anxiety symptom scales) and (c) mean anxiety levels (anxiety symptom scales). Initially, 537 unique papers were identified. Subsequently, 43 papers met criteria for inclusion in the review.

Results

Prevalence rates for ‘any’ anxiety disorder (as defined by either diagnostic clinical interviews or above cut-points on symptom scales) ranged between 4.1% and 16.0% during the prenatal period and 2.4–18.0% during the postnatal period. The data reviewed suggest the course of anxiety across the perinatal period is fairly stable with potential decreases postpartum.

Limitations

Wide variation in study measurement and methodology makes synthesis of individual findings difficult. Anxiety is highly comorbid with depression, and thus measures of mixed anxiety/depression might better capture the overall burden of mental illness.

Conclusions

Anxiety disorders are common for men during the perinatal period. Both partners should be included in discussions and interventions focused on obstetric care and parent mental health during the perinatal period.

Introduction

The perinatal period refers to both the prenatal stage which represents pregnancy, and the postnatal stage which represents the first twelve months following childbirth. There has been an increasing focus on women's anxiety during the perinatal period. However, the perinatal period is not only a unique time in mothers’ lives, but also the lives of fathers. It has been identified as a time of adjustment for men (Finnbogadóttir et al., 2003). Men's psychological distress at this time has been related to poor relationship satisfaction, financial burden, and poor job quality (Barclay et al., 1995, Buist et al., 2003, Giallo et al., 2013). It remains uncertain whether these broad stressors are intensified by the perinatal period (i.e. having a pregnant partner or infant), or whether they simply reflect the stressors common to most men during early adulthood to midlife. However, there are specific experiences unique to expecting/having an infant which may be related to increased distress at this time, such as extreme fatigue, poor partner and/or infant health, witnessing birth trauma, and feelings of inadequacy as a parent (Bradley et al., 2008, Carter et al., 2007, Giallo et al., 2013, Glazer, 1989). In addition, a review conducted by Swain suggests there are specific neurological processes or paternal cognitions unique to the brains of men with young children (i.e. increased emotion regulation), indicating that the perinatal period may be a unique time cognitively for men (Swain et al., 2014).

While there is reason to hypothesise that men's anxiety increases during the perinatal period, potentially due to increased stressors, we still don't know whether anxiety disorders are any more common for men during this life stage than prior to or after having an infant. This is, in part, because the prevalence of anxiety and the course (timing of onset, persistence) across the postnatal period is not well understood for men. To date, much of the literature investigating men's mental health during the perinatal period has focused on depression. For example, a meta-analysis by Paulson and Bazemore (2010) reported pooled prevalence rates of postpartum depression in men of 8% from birth to three months, 26% from three to six months, and 9% from six to twelve months. There has been no such similar meta-analysis or systematic review summarising the available research findings with regards to perinatal anxiety in men. The lack of review may be due to difficulties defining and specifying anxiety as separate from other related constructs such as stress, distress, and depression (Clark and Watson, 1991). In addition, the broad range of anxiety disorders available for assessment, (e.g. Generalised Anxiety Disorder (GAD); Panic Disorder (PD); Post-Traumatic Stress Disorder (PTSD) etc.) also poses a challenge when summarising the literature. However, there are strong indications that anxiety is common for men during the perinatal period, warranting further research and clinical attention. A recent Australian study by Wynter et al. (2013) found that anxiety was more common than depression for men during the first six months postpartum (n=172). Wynter reported that 4.1% of men experienced a diagnosable anxiety disorder (using criteria from the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV)) during the first six months postpartum, and a further 12.2% met the criteria for an ‘Acute Adjustment Disorder with Anxiety (AADA)’. Keeton et al. (2008) also identified a large number of ‘expecting fathers’ with high anxiety prior to childbirth. This study found 16.0% of men with partners in the third trimester of pregnancy scored higher than forty on the Spielberger State-Trait Anxiety Inventory (STAI-State), indicating a likely anxiety disorder (n=153).

In addition, several studies have tracked men's anxiety levels across the perinatal period to observe the course (or pattern) of anxiety and determine critical ‘peaks’ in symptomology. Research by Figueiredo and Conde (2011a) found that the prevalence of anxiety decreased across the prenatal period (first trimester −10.1%, second trimester −8.0%, third trimester −7.8%), and was then lowest at three months postpartum (4.4%). In the postnatal period, Condon et al. (2004) found anxiety levels were stable across three, six and twelve months. Linking these, and other, disparate pieces of research together is necessary to better clarify common trajectories of anxiety symptoms and disorders for men across the perinatal period. In turn, this knowledge about the course of men's anxiety is needed to identify the optimal stages when prevention, intervention and service provision should be targeted.

While there has been substantial growth in the number of studies reporting single-time-point data and repeated-measures (course) data for men's anxiety across the postnatal period, there has been little attempt to synthesise these findings. A systematic review of this literature is both timely and warranted. Collated data is needed to give a clearer picture of how prevalent anxiety is for men during the perinatal period. These data might then be compared with prevalence figures from the general population to infer whether the perinatal period is a time of increased risk for men. The adverse impacts of perinatal anxiety for both partners and children also highlight the need to better understand how widespread men's anxiety is at this time. Findings from Matthey et al. (2003) suggest that if men meet the criteria for an anxiety disorder during the perinatal period, their partners are approximately twice as likely to also meet criteria for an anxiety or depressive disorder. Similarly, fathers’ anxiety has been found to impact on childhood development in the early years, increasing the risks of infant negative affect (Potapova et al., 2014) and child internalising problems (Cimino et al., 2015) (for a review see Ramchandani and Psychogiou, 2009).

The aim of the current systematic review is to summarise the published literature reporting the prevalence and course of paternal anxiety disorders (and symptomology) within the prenatal period and the first postpartum year. Anxiety disorders reviewed include: Generalised Anxiety Disorder (GAD); Acute Adjustment Disorder with Anxiety (AADA); Panic Disorder (PD); Obsessive Compulsive Disorder (OCD); and Post-Traumatic Stress Disorder (PTSD). AADA is commonly assessed within postnatal studies in lieu of Generalised Anxiety Disorder (GAD), as a diagnosis of GAD requires six months symptom duration (e.g. Reck et al., 2008; Wynter et al., 2013). We note that the DSM-V does not include OCD, PTSD, and AADA within the anxiety disorders section (they are now in the Obsessive Compulsive and Trauma related sections), however they have been included in this review as the literature to date has typically classified them as ‘anxiety disorders’ (Association, 2013, Ross et al., 2006). When investigating anxiety symptomology (e.g. continuous self-report assessments) we specifically investigate ‘anxiety’ as distinct from other related constructs such as stress, psychological distress and depression. Previous research suggests that while anxiety is significantly correlated with these related constructs, it specifically reflects heightened experiences of physical hyper-arousal and fear (Clark and Watson, 1991, Lovibond and Lovibond, 1995). The reporting of this systematic review follows the protocols outlined in the PRISMA guidelines (http://www.prisma-statement.org/statement.htm (Moher et al., 2009)).

Section snippets

Search strategy

Five databases (PubMed, PsycINFO, Cochrane, SCOPUS, and Web of Science (Social Science Index)) were searched for relevant scientific articles published prior to April 2015. Search terms included terms referring to fathers, the perinatal period and anxiety. Specific search terms were: (father* OR paternal OR dad) AND (pregnancy OR childbirth OR postpartum OR postnatal OR perinatal OR antenatal OR prenatal) AND (anxiety OR panic OR phobi* OR obsessive-compulsive OR OCD OR post-traumatic stress OR

Study characteristics

Table 1, Table 2, Table 3, present information about the individual study characteristics in addition to the reported prevalence rates for anxiety disorders and mean scores for anxiety symptom scales. The review found that 43 papers met criteria for inclusion in the review. Sixteen (37.2%) of the papers reported prevalence data (Table 1, Table 2), and 31 (72.1%) papers reported means data (Table 3).

Discussion

The current systematic review identified forty-three studies that reported data for men on the prevalence of anxiety disorders and/or average anxiety levels during the prenatal and/or postnatal period. The review found sixteen articles that reported prevalence estimates (of either a ‘probable’ or diagnosed anxiety disorder) and thirty-one articles that reported summary means data (using anxiety assessment scales). Overall, the data suggests anxiety is common for men during both the prenatal and

Role of Funding Source

The primary funders for this research (beyondblue and The Movember Foundation) and the other secondary funders listed as support for the authors (NHMRC, La Trobe University, Murdoch Childrens Research Institute, Victorian Government), did not play any role in the study design, data collection, interpretation of the results, writing of the report, or the decision to submit the article for publication. The findings and views reported in this paper are those of the authors, and should not be

Conflict of interest

None.

Author Contributions

LL and CP designed the literature review. LL, CP, AC, RG all contributed to the design of the research questions. LL and CP conducted the systematic literature review (CP conducted the database searches, LL and CP conducted the data screening and extraction). LL, AC and RG drafted the manuscript for the review. All authors have contributed to the final draft of the manuscript, and have approved the final article for submission.

Acknowledgements

This research was funded by beyondblue with donations from The Movember Foundation (National Priority Driven Research Grant round 2011 (#LEAC11NPD)). LL is funded by an Australian National Health and Medical Research Council (NHMRC) Early Career Fellowship #1035803. AC is supported by the Roberta Holmes Transition to Contemporary Parenthood Program, Judith Lumley Centre, La Trobe University. RG was supported by an Murdoch Childrens Research Institute Career Development Award and the Victorian

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