Early-Onset and Delayed-Onset Postpartum Psychosis: A Case Series

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The first sentence of the abstract and introduction to the manuscript are almost identical, but they indicate a different incidence of postpartum psychosis – this should be standardized. The content should be modified and no duplicate sentences should be used.
Does the literature indicate risk factors for postpartum psychosis such as: unwanted pregnancy, a demanding child, lack of antenatal education, or lack of participation in childbirth classes?
Was the mental state of the women included in the study monitored during pregnancy, e.g., using the EPDS?
The conclusions should be modified – they are not conclusions. The small sample size is not a conclusion but a limitation of the study.

Author Response

Reviewer 1:

 

Comment 1: "The first sentence of the abstract and introduction to the manuscript are almost identical, but they indicate a different incidence of postpartum psychosis – this should be standardized".

 

Response 1: Thank you. We modified it.

 

Comment 2: "The content should be modified and no duplicate sentences should be used."

 

Response 2: Thank you. We revised it.

 

Comment 3: "Does the literature indicate risk factors for postpartum psychosis such as: unwanted pregnancy, a demanding child, lack of antenatal education, or lack of participation in childbirth classes?".

 

Response 3: While an unwanted pregnancy, a demanding child, lack of antenatal education, or lack of participation in childbirth classes could be related to postpartum depression in some studies, they do not appear to directly cause postpartum psychosis. On the other hand, they are a significant risk factor that can increase distress and emotional turmoil, raising the chances of developing the PPP condition, but we did not find articles supporting these risk factors. We added a new Table with the summary of most known PPP risk factors at this moment.

 

Comment 4: "Was the mental state of the women included in the study monitored during pregnancy, e.g., using the EPDS?".

 

Response 4: Not systematically. In fact, we do not use standardized scales in our clinical practice, except for specific cases of diagnostic studies.

 

Comment 5: "The conclusions should be modified – they are not conclusions. The small sample size is not a conclusion but a limitation of the study".

 

Response 5: We included “conclusions” as “Final remarks”.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript is well-written and has merit. Some aspects to consider:

• Lines 69-73 (page 2): explore on these predictive models for PP. For naïve readers, this is crucial.
• Same page: more rationale is needed for the statement “difficult to analyze”. What do you mean?
• The results section looks a bit incomplete. I think a Table fully describing the results from the anamnesis would be great. What medications, dosage, time on the medication were the patients on?
• Your X2 statistics would read better on a table. Also, perhaps you did not meet the requirements for X2, given you sample size. Double-check this as Fisher’s test might be what you are looking for.
• Also, description of cases is missing. This is what classically mean “series of cases”. I suggest authors to read guidelines for case reports and revamp the results section.
• The discussion has excellent content, but it is hard to follow. Adding subheadings might help.

Author Response

Reviewer 2:

 

Comment 1: "The manuscript is well-written and has merit. Some aspects to consider: Lines 69-73 (page 2): explore on these predictive models for PP. For naïve readers, this is crucial."

 

Response 1: Thank you. We explore predictive models in detail in Discussion.

 

Comment 2: "Same page: more rationale is needed for the statement “difficult to analyze”. What do you mean?".

 

Response 2: Thank you. You are right. We want to say “difficult-to-obtain low prevalence sample”.

 

Comment 3: "The results section looks a bit incomplete. I think a Table fully describing the results from the anamnesis would be great. What medications, dosage, time on the medication were the patients on?".

 

Response 3: We improve Table 1.

 

Comment 4: "Your X2 statistics would read better on a table. Also, perhaps you did not meet the requirements for X2, given you sample size. Double-check this as Fisher’s test might be what you are looking for."

 

Response 4: Yes. It is Fisher’s exact test.

 

Comment 5: "Also, description of cases is missing. This is what classically mean “series of cases”. I suggest authors to read guidelines for case reports and revamp the results section."

 

Response 5: We review the results section and include new data.

 

Comment 6: "The discussion has excellent content, but it is hard to follow. Adding subheadings might help."

 

Response 6: Thank you. We added subheads.

Reviewer 3 Report

Comments and Suggestions for Authors

This study focuses on describing the 25 characteristics of episodes occurring within the first postpartum year, specifically 26 examining clinical, etiopathogenic, and prognostic differences between immediate- or 27 early-onset PP (≤15 days postpartum) and delayed-onset PP (onset after several weeks).

1) The most important thing is that the sample size is too small to interpret the data. Although the authors mentioned it as a limitation, it is not interesting for readers. 

2) The conclusion explains limitations without a focus on the main findings of the study. 

3) One concern I have as I read your manuscript is that you don’t address the issue of the lack of direct proof of causality. 

4)Discussion: Different previous research and case series have shown inconsistency on the definition of early-onset or delayed onset PPP. In fact, the postpartum onset period is also considered differently across studies and series. In the present study, I did not find consistency.

Author Response

Reviewer 3:

 

Comment 1: "This study focuses on describing the characteristics of episodes occurring within the first postpartum year, specifically examining clinical, etiopathogenic, and prognostic differences between immediate- or early-onset PP (≤15 days postpartum) and delayed-onset PP (onset after several weeks). 1) The most important thing is that the sample size is too small to interpret the data. Although the authors mentioned it as a limitation, it is not interesting for readers".

 

Response 1: Yes. It is a small sample, but the proposal of a better definition of the onset (probed or not) is very scientifically interesting for readers interested in the PPP.

 

Comment 2: 2) The conclusion explains limitations without a focus on the main findings of the study.

 

Response 2: We included “conclusions” as “Final remarks”.

 

Comment 3: 3) One concern I have as I read your manuscript is that you don’t address the issue of the lack of direct proof of causality.

 

Response 3: We included it.

 

Comment 4: 4)Discussion: Different previous research and case series have shown inconsistency on the definition of early-onset or delayed onset PPP. In fact, the postpartum onset period is also considered differently across studies and series. In the present study, I did not find consistency.

 

Response 4: We change inconsistency for “lack of agreement”.

Reviewer 4 Report

Comments and Suggestions for Authors

1-)The abstract clearly identifies the clinical importance of postpartum psychosis and provides epidemiological context (incidence 1 in 1,000 births).

2-)The study addresses a novel and clinically relevant distinction—immediate/early vs. delayed onset—within the first postpartum year.

3-)you can remove  the word statistically from the abstract.

Five patients experienced30
immediate or early decompensation and five experienced delayed onset. None of the31
variables analyzed showed a statistically significant association with the timing of32
decompensation (p > 0.05).

4-)the following maybe not necessary

vA larger sample size36
is likely needed to detect statistically significant effects

5-)authors can mention gap in the literature.

6-)please add more keywords.

7-)please add more references to support introduction.

8-)please give information about patient selection criteria.

9-)please mention how many doctors collected the data.

10-)if possible, calculate effect size.

11-)there are typos in the table such as dagnosis. please correct it.

 

Comments on the Quality of English Language

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Author Response

Reviewer 4:

 

Comment 1: "1-)The abstract clearly identifies the clinical importance of postpartum psychosis and provides epidemiological context (incidence 1 in 1,000 births)".

 

Response 1: Yes. We included exactly the incidence of 1 to 2 cases in 1,000 births.

 

Comment 2: "2-)The study addresses a novel and clinically relevant distinction—immediate/early vs. delayed onset—within the first postpartum year".

 

Response 2: Thank you.

 

Comment 3: "3-)you can remove  the word statistically from the abstract"."Five patients experienced immediate or early decompensation and five experienced delayed onset. None of the variables analyzed showed a statistically significant association with the timing of decompensation (p > 0.05)".

 

Response 3: Thank you. We did it.

 

Comment 4: "4-)the following maybe not necessary - vA larger sample size is likely needed to detect statistically significant effects".

 

Response 4: Thank you. We removed it.

 

Comment 5: "5-)authors can mention gap in the literature".

 

Response 5: We include it.

 

Comment 6: "6-)please add more keywords".

 

Response 6: We added it.

 

Comment 7: "7-)please add more references to support introduction".

 

Response 7: We added it.

 

Comment 8: "8-)please give information about patient selection criteria".

 

Response 8: We include more information.

 

Comment 9: "9-)please mention how many doctors collected the data".

 

Response 9: We mentioned it. It is very different in every case.

 

Comment 10: "10-)if possible, calculate effect size".

 

Response 10: It is very difficult to obtain with these small samples and non-parametric tests. We are planning to include in the future a greater prospective sample together with other hospitals in the area.

 

Comment 11: "11-)there are typos in the table such as "dagnosis". please correct it".

 

Response 11: Thank you. We change Table 1.

 

 

Thank you,

 

The Authors

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript was revised according to the guidelines.

Reviewer 2 Report

Comments and Suggestions for Authors

Authors complied with the comments quite well. Just a minor typo: X2 statistics is not the same as Fisher's Exact test. This should be double-checked before going online.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you very much for revising the manuscript. I recommend acceptance

Reviewer 4 Report

Comments and Suggestions for Authors

thank you very much.

I accept it.