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5 The Role of Paternal Mental Health During the Perinatal Period…
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increased risk of malformations (most frequently in the urinary tract) was diazepines, oxazepines, thiazepines, and oxepines (such as antipsychotics), which showed
a moderately elevated adjusted OR of 1.22 but not statistically signicant. However,
there is no clear link between the drug and the malformation. The trend of increased
risk for diazepines, oxazepines, thiazepines, and oxepines could be due to the underlying disease rather than the drug. It is not currently known whether paternal use of
these drugs during sperm development is associated with the risk of birth defects.
Further research is needed, with the current study primarily focusing on SSRIs and
valproic acid.
5.3.1 The Impact ofPaternal Psychopharmacotherapy: Selective
Reuptake Inhibitors (SRI)
The use of selective serotonin reuptake inhibitors (SSRIs) has grown since their
introduction in the 1980s (Kendrick 2021). Studies suggested that paternal use of
these medications may harm male fertility and fetal development. Some studies also
reported that SSRIs seemed to be associated with lower semen concentration,
reduced total sperm count, decreased sperm motility, altered sperm morphology,
and increased sperm DNA fragmentation (Yland et al. 2021). However, other
research has concluded that SSRIs do not directly impair semen parameters,
although a signicant difference in sperm morphology has been observed with escitalopram use (Pham etal. 2022). Two Scandinavian cohort studies (Engeland etal.
2013; Wensink etal. 2022) have investigated the effects of preconception paternal
SSRI use on major congenital malformations and preterm birth nding no increased
risk of major congenital malformations, but reporting a higher risk of preterm delivery. A study conducted by Garvik etal. (2024) examined the relationship between
paternal SSRI use within 3months before conception and adverse health outcomes
in offspring, including birth outcomes and early life events during the rst year of
life. The study did not nd any statistically signicant increased risk for low Apgar
scores, being small for gestational age (SGA), or major congenital malformations.
However, citalopram and escitalopram were associated with a statistically signicant 1.15-fold increased risk of preterm birth. Regarding adverse early life events,
no clinically signicant risks were associated with paternal SSRI use overall, though
citalopram was linked to a 1.12-fold increased risk of hospitalizations during the
rst year of life. Some studies focused on the possible association between paternal
use of SSRIs and ASD or ADHD in offspring, despite conicting data. A study by
Viktorin etal. (2018) compared the incidence of ASD in children born to fathers
undergoing antidepressant treatment during the time of conception (from 4 weeks
before conception to 4 weeks after), children born to fathers who started antidepressant treatment during pregnancy, and children born to untreated fathers. No association was observed between the use of antidepressants during conception and ASD
or ID.Children whose fathers started antidepressant treatment during pregnancy
had a higher risk of ID (OR=1.66; 95%CI=1.06 to 2.59). A study based on Danish
national registers found that compared to unexposed children, exposed children had
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G. Francesconi et al.
a 1.62-fold higher risk of ASD (95% CI 1.33–1.96), particularly for fathers who had
used SSRIs in the year before conception (Yang etal. 2017). However, the slight
increase in risk may be attributable to paternal baseline psychiatric indications
related to SSRI use or other confounders. Yang etal. (2018) found that exposure to
SSRIs 1 year before conception showed a hazard ratio of ADHD of 1.35, while
paternal SSRI use only in the last 3months before conception had an adjusted HR
of 1.31, compared to non-exposed peers. However, the slight increase in ADHD risk
might be linked to the underlying conditions for which SSRIs were prescribed.
5.3.2 The Impact ofPaternal Psychopharmacotherapy:
Valproic Acid
Epilepsy is a prevalent neurological disorder among males of reproductive age
(Christensen etal. 2023). Valproate, a commonly prescribed antiseizure medication
(ASM), is frequently used to manage epilepsy in this population (Marson etal.
2021). In 2014, the European Medicines Agency (EMA) issued contraindications
for the use of valproate during pregnancy and restricted its use in female patients of
childbearing age due to teratogenic risks (EMA 2014). The potential risks associated with paternal exposure at conception remain unclear (Bromley etal. 2023).
Nevertheless, in November 2023, the U.K. Medicines and Healthcare Products
Regulatory Agency (MHRA) expanded these restrictions to include male patients,
stating that valproate should not be prescribed to patients younger than 55years of
age unless no alternative treatments are available (MHRA 2023). In January 2024,
the EMA recommended that valproate treatment for male patients should only be
initiated and supervised by specialists. These specialists should inform patients of
the potential risks, discuss the use of effective contraceptives for both the patient
and their partner, and conduct regular reviews to reassess the need for treatment,
particularly if the patient is planning a pregnancy (EMA 2024). These restrictions
are based on a retrospective observational study initiated by the EMA which suggested a possible increased risk of neurodevelopmental disorders (such as ASD) and
both major and minor congenital malformations in children conceived by men who
had taken valproate in the 3 months preceding conception (EMA 2023). However,
the EMA was unable to establish a direct causal link to valproate. Recent studies
(Sundelin etal. 2016; Brikell etal. 2018; Garey etal. 2024) reported an increased
risk of ASD and ADHD in children of parents with epilepsy, without, however,
mentioning any anticonvulsant therapy used. Moreover, recent literature, although
limited in data, has not demonstrated an increased risk of developmental disorders
associated with paternal exposure to valproate. These results were consistent across
various analyses, including comparisons with the general population, dose-response
assessments, sibling comparisons, and analyses limited to fathers with epilepsy.
(Tomson etal. 2020; Honybun etal. 2024; Christensen etal. 2024). According to the
literature, paternal valproate exposure may potentially impact male germ cells
(Sakai etal. 2023). Overall, current literature about the safety of other psychotropic
5 The Role of Paternal Mental Health During the Perinatal Period…
89
drugs in fathers is still limited. Therefore, further research is needed to draw denitive conclusions about the safety of other psychotropic medications.
5.4 Management Strategies
The prevalence of mental health issues among parents is difcult to estimate due to
underreporting and varying recording practices. However, estimates suggest that
between 15% and 23% of children live with a parent who has a mental illness
(Pierce etal. 2020). Dealing with families facing complex issues such as mental
health problems presents challenges. The separation between adult mental health
services and child-focused services, as well as between these services and child
protection, often hinders the integration of care. Fragmented services can exacerbate reliance on healthcare resources and deepen mental health issues in children,
particularly when parental mental health problems are present (Cooper etal. 2016).
It is important to educate fathers through multimodal prenatal education about
paternal perinatal depression in the form of in-ofce posters, verbal dialogue, and a
handout (Guillemette etal. 2023). Early diagnosis through screening tests is crucial.
Once the diagnosis is made, it is important to begin appropriate treatment including
both pharmacological and nonpharmacological treatments.
The effectiveness of cognitive behavioral therapy (CBT) in treating depression
and anxiety is well established, with benets that often extend beyond the end of
treatment. In some cases, CBT may even be more effective than antidepressant
medications. Nontraditional methods, such as internet discussion forums, e-therapy,
therapy tailored to align with masculine gender role norms, or group-based workshops (particularly if the group is exclusively male), show considerable promise
(O’Brien etal. 2017). CBT-based group interventions with the family may improve
parenting effectiveness and children’s coping skills to reduce stress related to parental depression, also proved successful for both parents’ and children’s mental health
(Compas etal. 2009).
Recognizing the success of home visiting programs aimed at supporting mothers
during the perinatal period, Hamil etal. (2021) developed the Fathers and Babies
(FAB) intervention to engage fathers. The FAB program consists of 12 sessions,
featuring digital components and running concurrently with the Mothers and Babies
(MB) intervention in participating families. It uniquely focuses on how fathers can
enhance both their own mental health and that of their partners. Feedback from
initial focus groups and survey responses indicated that the pilot program was wellreceived, feasible, and acceptable, with promising signs of effectiveness. In a similar vein, Kavanagh etal. (2021) developed a digital intervention designed for both
new mothers and fathers. The app features various modules covering topics such as
baby care, role transitions, self-care, and supporting partners. While there were no
signicant differences in depression and quality of life ratings between the intervention and control groups, participants in the intervention group did report greater
improvements in parenting self-efcacy scores. Another form of therapy is Parent–
Child Interaction Therapy (PCIT), which seems to be effective in reducing both
90
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children’s internalizing and externalizing symptoms. Additionally, it leads to
decreases in parental depressive symptoms and overall parenting stress (McCabe
etal. 2022). Psychopharmacological therapy should not be demonized, as the litera-
ture shows that the available data is limited and often conicting. It is therefore
essential to assess the risk-benet ratio on a case-by-case basis. Regardless of the
treatment modality, targeting both parent depression and parenting skills in conjunction appears to be critical to improvements in child mental health outcomes
(Cross etal. 2024).
5.5 Conclusions
This chapter has highlighted the importance of paternal mental health, an area that
is often overlooked but plays a crucial role in the emotional, cognitive, and behavioral development of children, underscoring the urgency of broadening the focus of
research and clinical practices, which have historically focused almost exclusively
on the maternal gure. The evidence gathered shows that conditions such as depression, anxiety, bipolar disorder, OCD, AUD, and SUD not only impact the quality of
the father-child relationship but can also have lasting repercussions on children’s
physical and mental health. Moreover, implications of paternal mental health on
family dynamics are equally relevant, including interdependence with maternal
mental health. Research should include an inductive investigation of fathers’ psychological, socio-environmental, and biological experiences, rather than simply
replicating studies on mothers. Parental role differences, based on biological sex
and cultural expectations, specically inuence parenting experiences, the risk, and
the clinical manifestation of mental health problems. It is important to overcome
barriers to accurate diagnosis of male depression and to analyze both parents’ experiences in parallel to understand the etiology and interaction of paternal and maternal mental health and long-term associations with child health. The integration of
early diagnostic approaches, innovative psychotherapeutic interventions, and educational programs for fathers-to-be could help improve the psychological wellbeing of the family.
Therefore, it seems essential to include the fathers in perinatal depression screening, also involving less common parenting structures, such as single fathers or
same-sex couples, to understand the unique experiences and risks that may affect
their children. In addition, it has emerged that the use of psychotropic drugs by
fathers requires careful evaluation to balance therapeutic benets with potential
risks to offspring. However, further research is needed to clarify the underlying
mechanisms and develop evidence-based guidelines capable of equally involving
both parents in the perinatal care journey. With a more inclusive and balanced
approach, the scientic and health community can help reduce gender disparities in
perinatal health and promote a healthier family environment conducive to the optimal development of the next generation.
5 The Role of Paternal Mental Health During the Perinatal Period…
91
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