RE: Supporting women who develop postnatal mental illness: What support do fathers receive to support their partner and their own mental health?

Recent interest has been shown regarding support provided for maternal postnatal mental illness. Fathers appear to play an important role within this support, however many feel alienated within maternal services. The current qualitative study aimed to investigate fathers’ experience of support provided to fathers, to help support their partner through postnatal mental illness. Twenty-ve fathers participated in an online questionnaire regarding their experience of their partner’s mental illness and the support provided to fathers. Thematic analysis revealed three main themes: ‘Support received to help support their partner’, ‘Support fathers wanted that was not received’ and ‘Father’s mental health’. These themes, and subsequent sub-themes, are discussed, highlighting an overall lack of support for many fathers, despite many wanting support on how to help their partner, and information on their own mental health and the services available. Fathers speci�cally wanted healthcare professionals to sign-post them to someone they can talk to for emotional support, and to be taught coping strategies which would help them to support both their partner and baby. The implications for these �ndings will also be explored, especially in light of the need to inform mental health support services.


Introduction
The arrival of a baby is often a joyous event.However some women present with mental illnesses such as depression, anxiety disorders, and postpartum psychosis during pregnancy or post-birth (Howard, Piot, & Stein, 2014).Worldwide, mental health problems are experienced by 10% of pregnant women and 13% of women who have recently given birth (World Health Organisation, 2019), and are the biggest single preventable killer of women in the late postpartum period; accounting for a quarter of maternal deaths, with one in seven of these from suicide (Oxford University, 2015).
The affected mother may struggle to interact with her baby in addition to experiencing physical and emotional changes.In some cases, this can negatively impact the child's growth and development (Sanger, Iles, Andrew, & Ramchandani, 2015;Challacombe et al., 2016).Appropriate mental health support can provide a range of long-term bene ts for the mother, the family including the baby, and wider society (NHS England, 2018).Support provided by healthcare professionals for maternal postnatal mental illness has improved in the last decade and can include self-help, psychological therapies, holistic approaches and specialist mother and baby units.However, inequalities in access to and experience of mental health services remain due to the lack of specialist perinatal mental health services (Coates, Ayers, & de Visser, 2014).The cost of the scarcity of such services to society is approximately £8.1 billion for each one-year cohort of births in the UK, with ¾ of that relating to the impact on the child (Bauer, Parsonage, Knapp, Lemmi & Adelaja, 2014).In recent years, NHS England has invested in extending these services, but data is not yet available regarding the impact of that investment.A woman's social network (i.e.their partner, family and friends) typically provides primary or additional support to the services offered by health care providers.Newly expecting mothers perceive their partner as their main support system (Rowe, Holton & Fisher, 2013).The majority of new mothers live with their child's father and perceive the father to have an important role in the support received (Leahy-Warren et al., 2012).Greater satisfaction with fathers' involvement in caregiving was reported to help reduce postnatal depressive symptoms in mothers (Fagan & Lee, 2010), while lack of support from the father can exacerbate mental health issues in new mothers (Wynter, Rowe, Burns, & Fisher, 2015).This suggests that a supportive father can have a positive impact on maternal mental health.Furthermore, fathers hold an important role in the recognition of their partner's mental health status.Speci c risk factors, such as previous mental illness, can provide valuable guidance for early identi cation of when a mother's mental health may be declining (Durrani & Cantwell, 2009).Supporting fathers' knowledge of these risk factors, the presentation of symptoms and knowing where support can be sought may encourage quicker selfhelp seeking and engagement with interventions by the mother.
Although research suggests that fathers' support likely bene ts mothers, many men feel excluded by healthcare professionals during pregnancy and the postpartum period.Evidence suggests fathers feel alienated and are unclear regarding their role within maternity services (Darwin et al., 2017).Many fathers report feeling isolated and ignored during and following traumatic birth experiences.Perceptions of trauma may occur following an emergency C-section or any other deviation from a birth plan, especially if there is potential risk of harm or death for the mother or child (Daniels et al., 2017).Oommen and colleagues (Oommen, Rantanen, Kaunonen, Tarkka, & Salonen, 2011) found that in Finnish mother and baby units, many parents experienced di culty adjusting to their new parental relationship and roles, but very little emotional support was provided.In some instances, fathers have felt supported during their partner's pregnancy (Daniels et al., 2017).However, even in these instances, the support fathers received was perceived as minimal and did not last into the birthing experience or postnatally.This indicates a diminished recognition of the father's role in supporting the mother's mental health, particularly within maternity services and by healthcare professionals.Nath et al. (2016) found that both poorer maternal mental health and marital con ict contributed to poor mental health in fathers.Mothers and fathers mental health are highly correlated, and fathers' risk of mental health problems during pregnancy and the perinatal period increases if their partner develops mental health problems.(Paulson & Bazemore, 2010), However, until very recently it was not even considered necessary to screen fathers for mental illnesses (Ramchandani et al., 2011).Fathers have con rmed their desire for greater recognition from healthcare professionals regarding the impact of postnatal depression on the family, and feel that the ability to seek support during pre-and post-birth may relieve some of their stress (Letourneau et al., 2012).Awareness of both partners' needs may be required in the treatment of maternal postnatal mental illness.To enable inclusion of fathers within maternal services, the lack of recognition regarding fathers' mental health and the possible reasons for this, men's experiences must be explored, particularly in regard to maternal mental health.The continued lack of recognition by healthcare professionals of father's mental health during pregnancy and the perinatal period, contributes to the wider lack of support.Fathers desire more communication around their partner's mental health than they currently receive (Marrs, Cossar, & Wroblewska, 2014).Speci cally, they desire information relating to their partner's treatment and medication (Reid, Wieck, Matrunola, & Wittkowski, 2017) to support their partner's health and to help ease their own concerns and anxiety.Current literature lacks understanding of how fathers would like this information to be communicated.
The current study aimed to explore fathers' experience of their partners' maternal postnatal mental illness, including the status of their own mental health during this period, and if any type(s) of support provided to them helped to support their partner.

Methods
Settings, sample and recruitment Twenty-ve fathers completed the survey.They were recruited voluntarily through mental health ambassadors with links to various mental health charities and fathers' support networks and advertisements on social media platforms (i.e.Facebook, Twitter).All fathers were aged 18 years or older, functionally uent in English, married or cohabiting at the time of study entry and had partners who had experienced postnatal mental illness were eligible to participate.Demographic information is shown in Table 1.

Procedure
An online questionnaire was created and distributed via Qualtrics Survey Software.Participants accessed the anonymous questionnaire from a link provided by the mental health ambassadors or the social media platforms.The questionnaire contained a mixture of open and closed questions which allowed for qualitative feedback regarding the father's perspective of their experience and the support given to them.Questions regarding the father's own wellbeing, and the support offered for this were also included.
Throughout the questionnaire development process assistance was provided from specialists in both questionnaire development and postnatal mental illness.

Data analysis
Data were managed using NVivo 10 and analysed using thematic analysis (Braun & Clarke, 2006) to allow detailed exploration of the responses.Responses were initially coded by one researcher (OB) to generate initial codes which were generated, expanded, excluded or merged into overarching themes.
Coding was an inductive and data-driven process, not informed by an a priori framework.Ten percent of cases and the overall authenticity of the themes were checked and veri ed by a second researcher (AM).
Re ective notes were taken throughout analysis which allowed for complete transparency of the analytical process.

Ethics
Approval was granted by Bournemouth University Faculty of Science and Technology Research Ethics Committee.Informed consent, anonymity, con dentiality and the right of participants to leave the study at any time was preserved.In order to complete the study, participants were provided with an electronic information sheet and invited to con rm consent to take part.Upon completion, participants were provided with debrie ng information.Anonymity was ensured though the removal of identi ers.All data were stored con dentially in accordance with the General Data Protection Regulation (GDPR, 2018).

Results
Thirty-nine fathers responded to the questionnaire, however only twenty-ve were used in analysis due to the failure of those excluded to complete the questionnaire in full or failure to click the consent button prior to beginning the questionnaire.The nal three main themes were "Support received to help support their partner" (Sub-themes: "Not enough support/information", "Low quality support"); "Support fathers want that was not received" (Sub-themes: "Information on postnatal mental illness", "Someone to talk to", "Direct healthcare service support") and "Father's mental health" (Sub-themes: "Effect on own wellbeing", "Fathers' support services") (Figure 1).

Support received to help support their partner
This theme examined what help was provided to fathers to enable them to better support their partner through postnatal mental illness.This support also includes maternal and mental health services directed at the mother, and the mother and father's experience of interaction with these services from the fathers' perspective.This main theme contained two sub-themes, "Not enough support/information" and Low quality support".

Not enough support/information
A total of twenty participants reported not receiving any support or information regarding postnatal mental illness and how they could support their partner pre-or post-birth.The two participants who received information considered it inadequate.The remaining two participants believed they received enough support after the birth of their child, whilst another suggested that they did not need any support post-birth.The lack of support and information provided often left participants feeling confused and/or frustrated regarding how to help their partner, with some admitting it negatively affected their ability to support the mother.

"I didn't know how to help her." (P1).
Many participants, mainly those who did not receive any support, would have welcomed any type of support or information from healthcare professionals.Participants felt being asked if they required help or support would have been bene cial both pre and post birth.
"Any offer of help and support would be useful."(P2).

Low quality support
Participants who received support or information claimed the support provided by healthcare professionals was typically readable information (i.e.lea ets) and/or very brief verbal signposting to videos or other resources.In some cases this support was second-hand; information was narrated by partners to the participants.Only a very small amount of this information focused on postnatal mental illness.
"I read the information my wife was given."(P3).
No participants reported receiving good quality support directed speci cally towards them.Participants felt the lack of support suggested a reduced acknowledgement of the father's role in the mother's care."I received support but it was all so fast paced, it [information] didn't cover anything about the father and I felt lost."(P4).
Participants recalled poor information and/or unprofessional services within the healthcare setting, which contributed further to their sense of inadequate support being provided.
"[The] crisis team were useless, trying to call them after giving us a wrong number" (P5).
Those whose partner and baby were admitted to a mother and baby unit blamed poor healthcare facilities for limiting the amount of time they could support their partner following the birth.This created a stressful environment and situation for both parents.
"[I] had to go home as facilities wasn't there for me to stay" (P6).
In several cases, the perceived lack of support and information led both parents to seek help elsewhere.
"[We are] now saving in order to get private therapy" (P3).

Support fathers want that was not received
This second theme covered what type of support fathers would like to have received before and after the birth.This theme contains three sub-themes, "Information on postnatal mental illness", "Someone to talk to" and "Direct healthcare service support".

Information on postnatal mental illness
Most of the participants would like to have received more support and information both prior to and after the birth of their child.Many felt they would have bene ted from knowing warning signs for postnatal mental illness and ways to help their partner cope.Participants suggested information on their partner's speci c mental health condition would have supported them in understanding the condition, the symptoms and how to best help their partner.They felt this information would be best presented in the form of easy to access lea ets or other written materials available on the internet because these types of resources can be easily accessed at any time point.Several participants expressed concern about forgetting information they were verbally told about their partners condition by health care professionals, especially if the information was narrated during a stressful time (i.e., a partner having a psychotic episode).Several participants would have liked their partner's treatment and recovery plan explained by a healthcare professional.
"A specialist to sit with me and explain the situation and care plan."(P4).
Participants viewed having someone to talk to as a useful form of emotional support.Many felt they were given little to no emotional support, such as having someone to talk to, to cope with their own mental health issues.

Direct healthcare service support
Participants said they would have appreciated more engagement and communication from maternal healthcare providers, in addition to increased access to mental healthcare professionals for their partner.They believed that better guidance on their partners diagnosis and treatment could be obtained from a range of healthcare professionals.
"Some Mental Health support, as well as social worker support and referral to a therapist" (P8).
Participants suggested that women post-birth should be able to access services (i.e.counselling or talking therapy) where they could speak to a healthcare professional on their own without any family members or other healthcare professionals being present.Fathers felt that their partners might have been more likely to speak openly about their experiences when seen alone.
"we could have both seen the same therapist but individually and then together."(P9).
When discussing their own support needs, participants stated that they would have bene tted from training in coping strategies to help them both support their partner and care for their own mental health: "Having coping strategies and understanding how to keep calm!" (P5).

Father's Mental Health
The nal theme explores the participant's mental health during their partner's illness including any support they personally received from healthcare professionals and outside organisations.This theme has two sub-themes, "Effect on own wellbeing" and "Fathers' support services".

Effect on own wellbeing
Most fathers believed that some aspect of their overall wellbeing had been directly affected by their partner's mental health during the perinatal period.This often led to feelings of low mood, anxiety and general stress and affected physical areas of their life such as their ability to sleep, concentrate and even care for their child.
"I was scared.I could not sleep.My memory lapsed and I cried too often.

Made me feel like I couldn't be as supporting to my son" (P10).
Several participants stated that these heightened physical changes and emotional responses had a negative impact on their relationship with their partner resulting in arguments, spending time apart and a decline in the support they offered each other: "Things became very di cult and pushed us apart."(P7).
Nevertheless, some participants con rmed that although the perinatal period was a stressful time, they were able to cope with the emotional demands, suggesting that they were either more resilient to the emotional effects of their partner's mental illness, or less willing to admit vulnerability.Several of the participants felt they needed to be seen to remain emotionally and mentally strong to support their partner and baby, despite coping with their own mental health.
"It was challenging supporting my partner and baby and managing with my own mental health, but I coped" (P11).

Fathers' support services
Participants rarely received support for their own mental health, and support received was reported as minimal.This lack of support from healthcare professionals led to fathers experiencing feelings of isolation and confusion around their own mental health issues.
"My wellbeing was of little interest to midwifes, health visitors… [I] had not given birth so had no cause for sympathy.A lea et for my wife and a page for the fathers to read which wasn't enough" (P10).
Participants agreed there was not enough information (and reassurance) on father-child bonding activities, something which they worried about, leaving new fathers feeling they were forgotten or treated with little sympathy."There was no information ….. how to understand that it could take a while for your child to bond as it does with the mothers" (P10).
Consequently, some participants felt there was an extreme imbalance between the level of support fathers receive from healthcare professionals compared to mothers.
"Mothers have support from midwives and health visitors, but dads get nothing" (P12).
Although participants acknowledged that the focus should primarily be on the woman, as she carries the baby and gives birth to their child, they still felt fathers should be offered more information and support than that currently made available by healthcare professionals."I understand the focus was and should be on my partner, but a bit of concern … would have been most welcomed."(P11).
Any "better-quality" support participants received for their mental health problems was typically provided by organisations outside of the major healthcare services.Participants felt high quality services directed towards fathers' mental health within current healthcare providers was currently inadequate, but were able to access support from external organisations and groups."I'm now getting [the] support that I need as I did meet with a fathers group where Mark was present, and what a great help he was" (P13).

Discussion
The current study explored fathers' experience of their partner's postnatal mental illness and the support provided to them, during this time, to help support their partner.Fathers are at risk of mental health problems during this timeframe, expressly if their partner develops mental health problems.Until very recently it was not even considered necessary that fathers should be screened to determine if they are experiencing symptoms of a mental health condition (Ramchandani et al., 2011).Fathers have con rmed their desire for greater recognition from healthcare professionals on the effects of postnatal depression to the whole family (Letourneau et al., 2012).Without this type of recognition by healthcare teams, symptoms of poorer mental health in fathers may be missed.Fathers being able to seek support during the pregnancy and perinatal stage may relieve some of the stress and overwhelming feelings they may be experiencing (Letourneau et al., 2012).Awareness of both partners' needs may be required in the treatment of maternal postnatal mental illness.
The variety of diagnoses participants had allowed for greater understanding of support offered for all postnatal mental illness, not just postnatal depression.Many fathers also spoke of the negative impact their partner's mental health had on both their emotional and physical wellbeing.Fathers received little to no support yet desired speci c types of support to be able to help their partner, as well as themselves.Similarly, Darwin et al. (2017) found that fathers felt isolated within maternal services and confused regarding their role.However, Darwin et al. (2017) stated that most fathers felt that the focus should be on their partner, whereas within the current study, many fathers felt frustrated that they had not been included in the support and information provided.This difference may be due to the current study focusing on maternal postnatal mental illness rather than maternal services overall.Maternal postnatal mental illness may have led some fathers to believe that they should take a more active role in their partner's care due to the more challenging circumstances.This further suggests that fathers may be more likely to desire involvement in extreme circumstances.
Participants highlighted that support received was often insu cient to help with what followed.This mirrored ndings from Daniels et al. (2017) in which fathers felt that support was minimal and not provided throughout the perinatal experience.Although the research conducted by Daniels et al. (2017) was related to birth trauma, and not postnatal mental illness, both studies recognise speci c areas within support services that may be lacking during a very stressful time for fathers, such as informational support and aftercare.This suggests a need for education among staff members in order to improve parent and healthcare provider services, communication and relationships.
Many fathers would have liked an offer of support.This suggests a distinct lack of support currently offered to fathers.Similarly, Daniels et al. (2017), in a study of fathers' experiences of birth trauma, also found that many fathers would have liked a lot more general support, ranging from simply being acknowledged to written information which can be referred to at a later date.The ndings from these studies raise the need for greater acknowledgement of fathers experiencing stressful situations, with even a small amount of support having a potential perceived bene t to new fathers.
Fathers desired more information speci c to postnatal mental illness, such as warning signs and potential symptoms, and information on how best to help their partner through this di cult time.Similar ndings were reported by Reid et al. (2017).The qualitative study identi ed the experiences of 17 fathers when their partners were admitted with their infants to a Psychiatric Mother and Baby Unit.The study identi ed that fathers' desire information relating to their partner's treatment and medication, and recommended the provision of an information pack and regular one-to-one meetings between fathers and healthcare staff (Reid, Wieck, Matrunola, & Wittkowski, 2017).
Many fathers highlighted that they would have liked improved communication with professionals regarding their partner's condition to help them understand the situation.This nding was con rmed in an earlier qualitative study by Marrs et al. (2014), which explored eight fathers' paternal roles and relationships when their partner and baby were admitted to a Perinatal Mental Health Unit.Fathers also felt they would have bene tted from having someone to talk to regarding their emotional needs, in line with research by Letourneau et al. (2012), where fathers stated that they would have bene tted from having someone to talk to.
Fathers wanted more interaction with and involvement from healthcare professionals, particularly specialists in mental health.This was primarily in relation to their partner's need for greater service involvement and access to professional help.Similarly,  2016) suggested that this marital con ict was a risk factor for depressive symptomology, whereas the current study appears to suggest the opposite.Further research is needed to determine the direction of causality between marital con ict and depressive symptomology.
There was a distinct lack of service support and general recognition for father's mental health.Many fathers felt little sympathy was provided to dads.This mirrored Letourneau et al. (2012) in which fathers desired a greater recognition of the impact of maternal mental illness on the family as well as awareness of paternal postnatal mental illness.The current study also found that this lack of support targeted towards fathers was more prominent within healthcare service providers.This was also mirrored in the birth trauma research by Daniels et al. (2017) in which many fathers felt they received minimal personal support following the birth.However, the current study did show an offer of support from some external organisations.Despite this, more focus should be paid to increasing sensitivity and support offered to fathers within the NHS, and other main healthcare providers.Through this, greater numbers of fathers in distress may be recognised and effectively supported.

Conclusion
Greater understanding from the current study, regarding the support fathers feel may be bene cial, can help generate future real-life applications.Most fathers in this study perceived informational support to be of the greatest value.Therefore, further information and guidance for dads regarding postnatal mental illness could be implemented throughout the perinatal stage to aid the father's ability to recognise and support their partner's mental wellbeing.This, in turn, could potentially lead to quicker help-seeking and recovery.This could be delivered in the form of written information, before the birth as an overview, or one-to-one through a healthcare specialist to enhance understanding, particularly in cases of newly diagnosed mums.In addition to this, as many fathers noticed a need for greater wellbeing support among dads, increased access to support for both partners could potentially improve overall wellbeing within the family.This could be delivered through a speci c mental health service for the mother, such as support worker aid, or talking therapy for the father as an aid to relieving stress.

"
[To be] made aware of symptoms, and it would have been good to know what to do when you suspected it [mental health problems]."(P7).

"
A basic understanding of depression and how to help [when] dealing with psychosis episodes … Lea ets on what to look out for, as you can't always remember what you are told in the immediate aftermath" (P6) Someone to talk to Several participants stated they would have bene tted from having someone to talk to about their situation.They felt it would have helped them to understand what was happening to their partner, what the options might be regarding their partner's treatment plan, and how they could support their partner.
Nath et al. (2016)16)highlights the lack of maternal mental health specialists in the Republic of Ireland.Lack of specialist services can, in turn lead to reduced service guidance for individuals with postnatal mental illness and their loved ones.AlthoughHiggins et al. (2016)explored the mother's personal experience, rather than the father's, both studies highlight the lack of access to speci c mental health services.Maternal postnatal mental illness appears to have a knock-on effect on many fathers' psychological and physical wellbeing.In support of this idea, research conducted by Nath et al. (2016) highlights how higher levels of depressive symptomology in new fathers appeared to be linked to postnatal mental illness within the mother.Early interventions to help fathers cope with stress may be needed in order to reduce the risk of future deterioration of emotional wellbeing.Further, in line withNath et al. (2016), fathers felt marital con ict was linked to their depressive symptomology.However,Nath et al. (