Introduction
Depression is one of the most common mental disorders during pregnancy, before, or after giving birth [1]. Depression before and after childbirth is not different from other types of depression in terms of severity and prevalence of symptoms; it is characterized by symptoms such as depressed mood, loss of interest and pleasure in daily activities, and at least three symptoms from the following symptoms: Psychomotor agitation or retardation, insomnia or excessive sleep, decisiveness, fatigue or lack of energy, suicidal thoughts, and mental confusion [2, 3]. Although postpartum depression has been studied mostly in women, there are evidences that show that men also experience depression after the birth of their baby, but postpartum depression in men usually starts later than in women [4]. Pregnancy is also a stressful phenomenon for fathers. Due to emotional connections with their wives, symptoms similar to those of depression may appear in them [5]. According to the results of two meta-analysis studies, the prevalence of prenatal depression in fathers is 8.4-10% [6, 7]; in the postpartum period, its prevalence is 6.6-13.6% [5, 8, 9, 10, 11, 12]. Prevalence of depressive symptoms in men may not be as obvious as depressive symptoms in pregnant women. It is associated with symptoms such isolation, agitation, paranoia, aggression, uncertainty, violence, anxiety, use of alcohol and illegal drugs, and illicit relationships [13]. Depression in fathers is also associated with adverse consequences such as the potential increase of psychiatric disorders in their children [10], adverse impact on child development [12] and unwillingness to participate in child upbringing. A study has shown that the prevalence of physical violence in children under 12 months with depressed fathers is higher than children with non-depressed fathers [8]. The prevalence of paternal depression in western countries is estimated at 24-25% [14]. It is more prevalent in men who become fathers for the first time [2]. This happens during the first 52 months after childbirth, especially during 3-6 months after childbirth, which reaches its maximum level due to fatigue and stress caused by taking care of the baby and the degree of satisfaction with marital life. Depression in fathers has a close relationship with depression in mothers [1]; however, no causal relationship between the two has been found yet [15].
Few studies have been reported in the field of prenatal and postpartum depression in fathers [16]. A study in Turkey showed that the prevalence of prenatal depression in fathers was 4.3%, while it was 1.7% in the postpartum period [17]. The studies conducted in Iran in the field of paternal depression are mainly focused on investigating this disorder in the postpartum period [18, 19].For example, Shamsi Khani showed that 45.8% of fathers suffer from postpartum depression [20]. Kamali Fard reported the prevalence of this disorder as 11.7% [18]. It seems that the reason for the difference in the prevalence rate is the different study population or the use of different assessment tools. Factors such as unemployment, weak marital relationship, low socio-economic level, number of previous pregnancies, unplanned pregnancy and stressful events cause prenatal and postpartum depression in men [13, 18, 21]. 
Despite the importance of the topic, evidence of factors related to prenatal and postpartum depression in Iranian men living in different cities are not available. Without diagnosis, there will be no care. With the occurrence of depression in fathers, family relationships are more damaged, and which have a negative effect on the growth and development of the children, especially on their emotional development [21]. Considering that today in a significant number of families in Iran, fathers are the primary and main caregivers of children and they play a more active role in taking care of their children compared to previous generations, it is logical that their mental health is also taken into consideration [18]. A review study on the factors related to prenatal and postpartum depression in Iranian men was not found. In this regard, this narrative review study aims to investigate factors related to prenatal and postpartum depression in men. Narrative reviews are widely used to review and analyze research evidence and are often used to group existing studies in a specific and broad field in terms of nature, characteristics, and volume, and represent an ideal overview to determine the scope or coverage of different studies on a specific topic [22]. It is expected that an estimate of the related factors can help health policymakers in designing and appropriate interventions for managing prenatal and postpartum depression in couples. The results of the present study can help improve the health of families.
Materials and Method
This is a narrative review study. By using keywords including paternal depression, prenatal depression, postpartum depression, and men both in Persian and English based on Medical Subject Headings (MeSH), an initial search was conducted in Google Scholar, PubMed, SID, Magiran, ProQuest, Web of Science, IranDoc, and Cochrane Library on related studies published from 1989 to 2022. First, 160 studies were found through searching in databases and 20 studies through reference searching. After finding duplicates by EndNote software, 60 articles were removed. Then, the abstracts of the articles were read and the articles that met the inclusion criteria were included in the study. The research and review articles and those with analytical and descriptive designs that focus on the factors related to prenatal and postpartum depression in men were included. In this step, 60 studies that did not meet the inclusion criteria were excluded. Finally, 60 studies were used for the review (Table 1) (Figure 1).


Results
The findings were classified into three general categories of biological factors, psychological factors, and social factors.
Biological factors
Age
Younger fathers (<25 years) are more likely to experience postpartum stress and depression than their older counterparts. Younger fathers, especially those who do not have no other children, face the challenges of having a baby, such as sleeplessness at night, changing baby’s clothes, feeding problems, and baby’s endless demands [23]. However, age alone is not a risk factor for postpartum depression in men [24].
Baby’s gender
Son preference exists in many cultures in South and East Asia and Africa. For example, in India, Pakistan, Egypt and China, there is a preference for a son [25]. Son preference is related to paternal depression during pregnancy [27]. In India, the abortion rate is higher for female fetuses, and a relationship has been reported between the birth of a female baby in families that prefer a son and postpartum depression [28]. The reason for son preference is the importance of the boys in the family economy and their role in helping with the agricultural work. In addition, boys are considered as the source of strength and social security [27]. In Western countries and European culture, there no such relationship, and due to the equality of the gender values, depression occurs less in these countries [28].
Unplanned pregnancy
Unplanned pregnancy has been reported as the most important variable and risk factor in causing the highest level of distress and depression during pregnancy and after childbirth in fathers [29]. Men’s lack of preparation to be a father can lead to more changes in their mood and make them prone to postpartum depression [30]. If fathers do not have time to prepare for having a baby, an unplanned pregnancy can add to their financial stress and cause them stress and anxiety during pregnancy. Paternal depression is more in men who are unemployed or belong to the low socio-economic group [31].
Sleep disorders 
Sleep disorders increase mood disorders in fathers during pregnancy and after childbirth. During the first few weeks after birth, parents have to adjust their sleep schedule based on their baby’s sleep schedule; hence, they may experience sleep disorders such as poor sleep quality, interrupted sleep, or insomnia, which may lead to potential mood disorders such as depression and anxiety [32]. Poor sleep quality and fatigue in fathers are also associated with postpartum depression [33], however, a paucity of studies have examined its relationship with prenatal depression in fathers. It is important to include fathers in the study of postpartum sleep disorders because they are not only at risk for depressive symptoms, but also sleep disorders may negatively affect their daily interactions with the family [34].
Psychological factors
Economic anxiety
Economic anxiety is known as a risk factor for paternal depression. Fathers with low monthly income have higher postpartum depression [35]. Due to the fact that the economic burden associated with the birth of a baby is on the fathers, the increase in expenses and their inability to pay them can expose fathers to mental pressure and psychological disorders such as anxiety and depression. Work environment and factors such as flexible working hours, maternity leave and work pressures are effective in causing paternal depression after childbirth [35, 36]. A man may work long hours and be praised and encouraged as a committed employee, while the underlying reason is that this work helps him relieve stressful thoughts and feelings [37].
History of illness
History of illness is a risk factor for depression in fathers, although it is not clear whether this history is related to their prenatal or postpartum depression. However, it make fathers prone to developing depression symptoms in the postpartum period [9]. The presence of some underlying or mental diseases in fathers make it difficult to recover from depression as quickly as possible, and sometimes they even aggravate the symptoms. The strongest predictor of fathers’ depression is the experience of visiting treatment centers for mental problems; despite the history of mental illness, the vulnerability of fathers to mental problems increases the risk of postpartum depression in them [30].
Maternal postpartum depression
Depression of one of the parents is the biggest risk factor for causing depression in the other one [38, 39]. Undoubtedly, the mother’s depression and her inability to take care of the child and deal with household chores can cause negative mood changes in her husband. On the other hand, it has been shown that the presence of depression or anxiety in fathers prevents them from fulfilling their main duties in caring and creating security for his partner [38]. The negative impact of fathers’ depression on their wives’ behavior in the months after childbirth can be seen as the father’s failure to perform his basic duties towards his wife and child, which also hinders the establishment of a good relationship between mother and child [39, 40]. It should also be noted that in societies where maternal postpartum depression is higher, the risk of depression in fathers is also higher, and maternal depression is a risk factor for paternal depression, because of the lack of appropriate and sufficient support from mothers to fathers, which leads to a feeling of powerlessness, despair and lack of control over the situation in fathers [6, 41].
Use of antidepressants and tobacco
Smoking causes many physical and mental diseases including depression and anxiety, abnormal behaviors and chronic diseases. Addiction to substances, including nicotine, occurs quickly and is strongly influenced by environmental conditions. The negative effects of alcohol and drug consumption in terms of psychological and neurological fields have also been proven. Some substances can affect both mental state (mood) and external activities (behavior) [42]. Violent behavior with wife, marital behavior outside the family framework, fear and anger are more common in depressed men [43].
Social factors
Lack of social support
Social support means receiving information, instrumental assistance, health advice, and emotional support from people whom a person is interested in or from the person’s social network, such as spouse, relatives, friends, and co-workers [44]. Previous studies have shown that lack of social support is an important risk factor for postpartum depression, while strong social support act as a protection against prenatal and postpartum against depression [45]. The existence of family disputes and problems with the wife’s family, lack of social support, having emotional deficiencies, not feeling calm and not being understood by family members, especially the wife, can be very important in aggravating the level of paternal depression [46].
Marital disputes
One of the most important factors that lead to the growth and survival of the family is compatibility and understanding between couples. Marital satisfaction is one of the main components of the marital system and affects an important part of a person’s life. Marital satisfaction is defined as a couple’s satisfaction with the fulfillment of their needs by their partner. The compatibility of the existing situation with the conditions of the person in the marital relationship depends on the conditions expected by the person [47]. Marital satisfaction is the feelings and emotions accompanied by pleasure that are experienced by couples, and these feelings are accompanied by considering the common aspects of life. The situation where couples feel happy and satisfied with each other most of the time is defined as marital satisfaction [48]. Dissatisfaction with marital relationships is a risk factor for postpartum depression in fathers and mothers. Depression in fathers increases conflicts in marital relationships and makes mothers more vulnerable to depression. On the other hand, for children whose mothers are already depressed, having a responsible and nurturing father protects them from some of the negative effects of maternal depression [49, 50, 51].
Discussion
The present study was conducted with the aim of reviewing the factors related to paternal depression during pregnancy and after childbirth. In addition to mothers who may experience prenatal and postpartum depression, fathers may have these depression symptoms under the influence of several factors, since pregnancy is a stressful event for them. A small number of studies have exclusively investigated the postpartum depression in fathers [52]. In a study, postpartum depression in fathers in China was estimated at 10.8%, and in Brazil, this value was 11.9% [36, 53]. In men whose wives had also postpartum depression, this rate reaches 24-50%. In a study in Tehran, Iran, the prevalence of postpartum depression in fathers was reported as 11.7% [54, 55].
The findings showed that many biological, psychological and social factors can affect prenatal and postpartum depression in fathers. Factors such as the old age of the father [23],  unplanned pregnancy [30], and sleep disorders [34] can cause prenatal and postpartum depression in men. Moreover, father’s economic anxiety and unemployment [36], history of illness [9], perceived stress [56], gender preferences such as the desire to have a boy [57], history of depression and anxiety during pregnancy, wife’s depression during pregnancy and after childbirth can affect prenatal and postpartum depression in men [18]. Among social factors, lack of social support, dissatisfaction with marriage and marital life, and communication problems were the factors contributed to the formation of paternal depression during pregnancy and after childbirth [45, 47].
The results of the studies showed that there was a significant relationship between the gender expected by the father or the mother and the incidence of postpartum depression; more depression was observed in cases whose gender of the baby was not based on the father’s or mother’s expectations. This result is consistent with the study of Forouzandeh et al. [58] and Hosseini et al. [44]. This can be due to the cultural issues of the families due to the special attention given to the male gender as a supporter in fulfilling family and work responsibilities. In the study by Zangeneh et al., no significant relationship between the gender of the baby and depression was observed [55].
In relation to psychological factors, the studies indicated that the presence of depression symptoms in pregnant mothers was the most important predictor of depression in fathers, such that the occurrence of postpartum depression in men whose wives were depressed was reported up to 50% [9]. This rate of postpartum depression prevalence in fathers can be due to demographic differences, different methods and tools used in the studies, and fathers’ history of illnesses. It should be noted that in societies where postpartum depression is higher in mothers, the risk of paternal depression is also higher, and maternal depression is a risk factor for paternal depression. Postpartum depression in fathers is related to anger and interpersonal conflicts. To cope with depression, men are more likely to turn to deviant or distracting behaviors such as over-engagement in work, sports, hobbies, eating, using the Internet, video games, watching TV, sexual activities, and gambling [37]. Other important reason for paternal depression in the postpartum period is that the emotional life of fathers after the birth of the baby is usually neglected, due to the focus of the family and surrounding people on the mother [52]. Other factors include having a history of depression, social and occupational problems, lack of self-confidence, financial problems, lack of intimacy, and lack of preparation for fatherhood [24]. These factors not only affect the fathers’ quality of life, but also affect all family members [53]. Postpartum depression in fathers should be considered because it can affect their ability to compromise in caring for the baby. It also affects their interaction with the child, because fathers who are depressed establish less emotional contact with the child and will not be able to support the child. This causes a feeling of weakness and inadequacy in the father and rejection of the child, and as a result, the risk of behavioral problems increases in children aged 3-5 years. In addition, fathers are an important primary source of formal support for mothers in the postpartum period, and a father who suffers from depression during this period cannot support his wife, and as a result, it affects the relationship between them.
The previous history of depression and seeing a psychiatrist and the history of taking neuropsychiatric drugs were also among the factors that had a significant relationship with the incidence of paternal depression, consistent with the findings of Zanganeh [55], Khormirad [59] and Forouzandeh [58]. In addition, some behaviors such as reduced social performance, alcohol and substance use, medication use, violent behavior with spouse, having marital behavior outside the family framework, feeling fear and anger were more in depressed fathers. Other complications of postpartum depression in fathers include child neglect, family separation, self-harm, and even suicide as well as emotional, behavioral and cognitive problems in children [42, 60].
One of the limitations of this study was that although all articles met the inclusion criteria, some of the published articles may have been lost due to lack of access to a database or the full text of the articles. Another limitation of this study was not having access to the full text of some articles and the exclusion of the articles published in a language other than English or Persian. Despite these limitations, this review has strengths and practical implications in the health care system. Considering the importance of factors related to prenatal and postpartum depression in fathers, they should be taken into account by experienced staff in hospitals and health clinics. The findings of this study can be used in quantitative or qualitative studies in the field of prenatal and postpartum depression in men. The role of various psychological, educational and counseling interventions in improving paternal depression should be addressed to obtain comprehensive studies in this field. Therefore, it is recommended to conduct a meta-analysis study to evaluate paternal depression interventions. The results of this study can be useful in achieving the goals of mental health policies for men, because they are considered as the head of households.
Conclusions
Factors related to prenatal and postpartum depression in fathers are categorized as biological, psychological and social factors. The entire focus of the healthcare system should not be on the mental health of mothers after childbirth; fathers may also be harmed. The mental health and supportive role of fathers can be a suitable support for the mother and the baby. Therefore, the screening of fathers after childbirth should be done, and those at risk should be referred for treatment. It is important to consider long-term planning in this field. Researchers should investigate the prevalence of this disorder in Iran more in a more specific way to provide the appropriate solution and improve the mental health of fathers in the prenatal and postpartum periods according to influencing factors.

Ethical Considerations
Compliance with ethical guidelines
The ethics committee of Mazandaran University of Medical Sciences (Mazums) has approved this study with the ethics code IR.MAZUMS.REC.1397.2926.

Funding
This project was fully supported and funded by Mazandaran University of Medical Sciences and Student Research Committee of Mazandaran University of Medical Sciences

Authors' contributions
First draft: Fatemeh Hamidi; Design: Fatemeh Hamidi, Ezra Barouj Kiakolai and Zohra Shah Hosseini; Project implementation and analysis: Fatemeh Hamidi, Seyyed Hamzeh Hosseini and Zohra Shah Hosseini; All authors approved the final version of the manuscript.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the research committee of Mazandaran University of Medical Sciences.


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