The Antenatal Origins of Postpartum Distress: A Retrospective Longitudinal Analysis of Depression and Anxiety Trajectories

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

 

This manuscaript  investigates longitudinal trajectories of depressive and anxiety symptoms from mid-pregnancy to 12 weeks postpartum, it shows that perinatal distress in this cohort peaks antenatally and strongly predicts postpartum outcomes. The study is important because it challenges the traditional postpartum opinion  and provides l support for earlier screening and intervention during pregnancy.

 

In the abstract the  extremely high correlation reported between antenatal and postpartum EPDS scores (rho = 0.98) should be interpreted more cautiously in the abstract, because such near-perfect associations raise concerns about construct overlap, repeated-measure dependency, or limited variability rather than pure predictive power.

In the introduction the atuhors should  more explicitly state what conceptual or methodological gap this study fills beyond existing longitudinal cohorts, particularly given that similar trajectories have been reported previously; clarifying the unique contribution of the Romanian clinical context or health-care structure .

 

In the Materials and Methods the definition of “mental health services” is overly broad and heterogeneous, limiting interpretability of the treatment-related analyses. Authors should made a  further clarification on timing, intensity, and type of care would substantially improve causal inference.

The  authors should aknowdlege that the  reliance on non-parametric repeated testing without mixed-effects modeling limits the ability to account for within-subject correlation and potential confounders.

The authors should acknowledged more explicitly that  the higher correlations between scales and time points suggest possible redundancy or limited discriminative capacity of repeated self-report measures in this cohort

The interpretation of the “treatment paradox” risks overstating conclusions, as selection by indication and baseline severity likely explain much of the observed difference.

 

In the Discussion  the consideration  of antenatal depression as the “sole predictor” of postpartum outcomes should be softened to avoid causal overreach  taking into account tha this an observational study.

Thee authors should expand the Expanding on alternative explanations such as measurement inertia, unmeasured psychosocial confounders, or chronic pre-existing depression .

In the  conclusions there are  recommendations for “aggressive” early interventions , authors should made a clearer distinction between evidence generated by this study and hypotheses that require prospective interventional validation.

Author Response

We thank the Reviewer for the encouraging feedback and for recognizing the value of focusing on earlier screening and intervention during pregnancy. We appreciate the constructive suggestions regarding methodological transparency and the contextualization of our discussion. We have addressed all points raised, as detailed below. All reviewer comments are followed by our responses in blue italics and a description of the changes made in the revised version of the manuscript.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The article entitled “medsci-4101695_The Antenatal Origins of Postpartum Distress: A Retrospective Longitudinal Analysis of Depression and Anxiety Trajectories” presents a retrospective longitudinal cohort study examining the trajectory of depressive and anxiety symptoms from mid-pregnancy to 12 weeks postpartum among 125 pregnant women in Romania. Using validated screening instruments—the Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7)—administered at four time points, the study reports that depressive symptoms peaked during pregnancy rather than in the postpartum period and were strongly predictive of subsequent postpartum depression. Anxiety symptoms remained relatively stable during pregnancy and declined after childbirth. Women who accessed mental health services exhibited higher baseline symptom severity and a slower rate of recovery, suggesting that current interventions may stabilize symptoms but may not fully resolve distress in high-risk women. Overall, the findings support the need for earlier prenatal screening and more intensive, stepped-care approaches to perinatal mental health.

 

Strengths: Several strengths of the study can be highlighted:

    Longitudinal design  : Repeated assessments across pregnancy and the postpartum period allow the examination of symptom trajectories rather than reliance on cross-sectional associations.

    Use of validated instruments  : The application of EPDS, PHQ-9, and GAD-7 enhances measurement validity and facilitates comparison with existing literature.

    Clinical relevance  : Identification of an antenatal peak in depressive symptoms has important implications for the timing of screening and preventive interventions.

    Focus on service utilization  : The analysis of mental health service utilization provides valuable real-world insight into treatment patterns and recovery trajectories.

    Public health implications  : The findings support earlier and more proactive mental health care during pregnancy.

 

Limitations. However, the study also presents several notable limitations:

 

    Small sample size  : The cohort of 125 women limits statistical power and reduces the robustness of subgroup analyses.

    Single-center design  : Conducted in a single hospital, which restricts the generalisability of the findings to other healthcare settings or populations.

    Retrospective design  : Reliance on retrospective data introduces the potential for information and selection bias.

    Confounding by indication  : Women receiving mental health services had more severe baseline symptoms, complicating interpretation of treatment-related effects.

    Limited adjustment for confounders  : The abstract does not clearly specify adjustment for relevant sociodemographic, obstetric, or psychosocial variables.

    Short postpartum follow-up  : Outcomes were assessed only up to 12 weeks postpartum, limiting insight into longer-term mental health trajectories.

 

Comments and Points for Improvement:

1. Clarification of objectives: While the introduction effectively highlights the importance of the topic, a more explicit formulation of the study hypothesis and clearer objectives—ideally distinguishing between a primary and secondary objective—would strengthen the conceptual framework.
2. Clarify analytic methods: The statistical methods should be described in greater detail, including handling of missing data, adjustment for founders, and whether a sample size calculation was performed.
3. Address confounding by indication: The observed “treatment paradox” should be interpreted cautiously, with explicit discussion of baseline symptom severity and potential strategies to address this bias (e.g. stratification or propensity score methods).
4. Expand information on service utilization: Greater detail regarding the type, intensity, and duration of mental health interventions would improve interpretation of treatment-related findings.
5. Extend follow-up duration: Follow-up beyond 12 weeks postpartum would allow assessment of longer-term symptom persistence or recovery.
6. Enhance generalizability: Future studies including multiple centers and more diverse populations would strengthen external validity.
7. Improve presentation of results: Tables 1 and 2 should present not only proportions but also appropriate statistical comparisons to assess whether observed differences are significant.

Figure 4 should be improved, as its current quality limits readability and interpretation.

 

8. Strengthen discussion of limitations: Although the discussion appropriately contextualizes the findings within existing literature, the study's limitations—particularly the retrospective design, small sample size, and limited confounder adjustment—should be discussed in greater depth.
9. Align conclusions with results: The conclusions should be more closely aligned with the observed findings and the study's methodological constraints.

Author Response

We thank the Reviewer for the encouraging feedback and for recognizing the value of focusing on earlier screening and intervention during pregnancy. We appreciate the constructive suggestions regarding methodological transparency and the contextualization of our discussion. We have addressed all points raised, as detailed below. All reviewer comments are followed by our responses in blue italics and a description of the changes made in the revised version of the manuscript.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have provided a detailed, point-by-point response to the reviewers' comments and have made several revisions to the manuscript. Overall, the revised version shows a clear improvement in structure, transparency, and interpretation, particularly in clarifying the objectives, expanding the limitations, and aligning the conclusions with the study design. However, some key aspects remain insufficiently addressed or require further clarification and correction before the manuscript can be considered for acceptance.

 

The authors should:

1. Explicitly report the rationale for the sample size and statistical power in the manuscript.
2. Clarify whether analytical adjustments were made for confounding factors or clearly acknowledge their absence.
3. Ensure that Tables 1 and 2 include statistical comparisons, not just textual descriptions.
4. Provide quantitative support for Figure 4 (text or supplementary material).
5. Maintain a non-causal interpretation of the findings related to the use of mental health services.

Author Response

We thank the Reviewer for their continued engagement with our work and for acknowledging the improvements in structure and transparency. We have carefully addressed the remaining points regarding statistical reporting, table comparisons, and the interpretation of our findings. All reviewer comments are followed by our responses in blue italics and a description of the changes made in the revised version of the manuscript using track changes.

Author Response File: Author Response.pdf