Psychosis risk among pregnant women in Ghana.

INTRODUCTION: Psychotic illness, although is rare, has been reported in the perinatal period. Individuals diagnosed with psychotic illness tend to first exhibit psychotic-like experiences (PLEs), defined as subclinical psychotic symptoms that occur outside the context of sleep or drug use. However, there is a paucity of empirical data on PLEs in pregnancy to advance scholarly discourse and support professional practice. The current study investigated the prevalence and correlates of PLEs among pregnant women in Ghana, a West African state.
DESIGN: A cross-sectional survey design was used to collect data from 702 pregnant women who responded to measures of PLEs, COVID-19 concerns and behavioral maladies such as anxiety and depressive symptoms. Descriptive and inferential statistics, namely chi square, exploratory factor analysis, MANOVA and multinomial logistic regression were used to analyze the data.
RESULTS: The results showed that 54.2%, 27.3% and 18.5% of participants were at no/low, moderate and high risk for psychosis, respectively. A total of 44.4% participants were not distressed by PLEs, whereas 32.2% and 23.4% were a bit/quite and very distressed, respectively. Psychosis risk was elevated among pregnant women who were more concerned about the COVID-19 effects, scored high in suicidal ideation, depressive symptoms and sleep difficulties.
CONCLUSION: The study showed that psychosis risk is present in pregnancy. IMPLICATIONS: Screening for psychosis risk in pregnancy should be prioritized for pregnant women with behavioral maladies, including suicidal tendencies, depressive symptoms, sleep difficulties and heightened concerns about COVID-19.

Introduction

Psychotic illness is a rare mental health condition that has been reported among women in the perinatal period [1]. In the maternal mental health literature, limited attention has been granted to psychotic illness relative to anxiety and depression [2, 3]. The available data, nonetheless, suggest quite disturbing prevalence rates and burden of psychosis in the perinatal period. An earlier study found that approximately 59% of mothers recruited from mental health settings were diagnosed with psychosis [4]. In the United States, it has been estimated that about 700 out of 100,000 post-delivery women were hospitalized because of psychotic illness [5]. A study conducted among 745,596 first-time mothers in Sweden revealed that, 892 were hospitalized for psychotic illness and 436 had not previously been hospitalized for any psychiatric disorder [1]. Data on the prevalence of psychosis in pregnancy is limited in Africa owing to lack of studies. Previous studies addressing this topical issue have focused on the factors contributing to the development of mental health issues, including psychosis, post-delivery [6].

Psychotic illness is a major risk factor for death by suicide in childbearing women, with estimates suggesting that one in every 500 women with postpartum psychosis die from suicide [7]. The risk for other mental health problems such as bipolar and depressive disorders is highly elevated in women with a history of postpartum psychotic illness [8, 9]. Psychotic illness has been associated with adverse obstetric and neonatal outcomes such as antepartum hemorrhage, placental abruption, postpartum hemorrhage, premature delivery, stillbirth, premature rupture of membranes, fetal morbidities and mortalities [5, 10]. As a heterogeneous mental disorder, several risk factors have been documented, including childhood maltreatment [11], low socio-economic status, neighborhood level social deprivation [12]. Among the perinatal factors implicated in psychosis include diabetes in pregnancy, antepartum haemorrhage, preeclampsia, maternal stress during pregnancy, pre-pregnancy and pregnancy obesity and cord complications [12].

More importantly, studies have suggested that the psychotic pathway commences with what is referred to as psychotic-like experiences (PLEs) [13]. PLEs are subclinical symptoms of psychosis that do not meet the threshold for clinical diagnosis as psychotic illness [13, 14]. PLEs are very common in the general population, appearing first in adolescence and sometimes in childhood [15] and can be categorized as positive (e.g., perceptual abnormalities, delusional thoughts) or negative (e.g., social withdrawal, avolition) [16]. Among the common examples of the PLEs are hearing voices, seeing things, and smelling things that other people do not hear, see or smell, respectively. PLEs are unrelated to or occur outside the context of sleep or drug use [14]. Just like psychotic illness, PLEs have been associated with a decline in general health status and behavioral maladies such as suicidal tendencies, emotional disorders and illicit substance use [17, 18]. These behavioral problems can contribute to mortality and morbidity during and after pregnancy. Because some people with PLEs go on to develop psychotic disorders [13], there is the likelihood that some women diagnosed with postpartum psychosis exhibited PLEs during pregnancy and/or after delivery.

While the foregoing suggests that studies elucidating PLEs in pregnancy are extremely important, our understanding of psychosis risk in pregnancy is limited largely because the existing studies have overwhelmingly focused on persons who have been diagnosed with psychotic disorders [5, 8–10]. For example, in their study involving 40 mothers diagnosed postpartum psychosis in South Africa, Voges et al. found that substance use during pregnancy, postpartum abuse and lifetime experience of trauma were reported by the participants [6]. Understanding the prevalence and correlates of PLEs in the perinatal period can strategically support healthcare professionals in their effort to render basic mental health services to pregnant women. It is posited that screening for PLEs will enable health professionals to engage with pregnant women on their mental well-being such that those who score high on PLEs could be deemed as high risk for future psychosis. The work by Levey et al. involving Peruvian pregnant women appeared to be the first study to have focused on PLEs in the pregnancy period [7]. Levey et al. reported that 27% of the 2,059 pregnant women scored high on psychosis risk. As noted previously, studies dedicated to PLEs in pregnant women are extremely important. Thus, building on Levey et al.’s study, the current study investigated PLEs among pregnant women in Ghana. The study objectives were to investigate the prevalence of PLEs in pregnant women and secondly determine the correlates of PLEs.

Methods

Data source

Data were gathered from 702 pregnant women recruited from the antenatal clinics of four health facilities, namely University of Ghana hospital (n = 175, 24.9%), Alpha hospital (n = 239, 34%), Sanford Clinic (n = 87, 12.4) in the Greater Accra and St-Gregory Catholic hospital (n = 201, 28.6%) in the Central regions of Ghana. These facilities are patronized by pregnant women of different demographic backgrounds.

Study design and data collection

A cross-sectional design was used. The inclusion criteria for participating in the study were age ≥18 years, nulliparity/multiparity and completion of senior high school diploma or equivalent (i.e., 12 years of formal education). This requirement assured the participants were proficient in English. It was most practical to use English questionnaires as there are more than 10 languages spoken in the Greater Accra and Central region of Ghana. Pregnant women in their first (≤ 12 weeks of pregnancy), second (≤ 24 weeks of pregnancy) or third trimesters (≤ 36 weeks of pregnancy) were recruited for the study. The exclusion criteria were diagnosis of a mental disorder during pregnancy and/or a history of mental health disorder. Data were collected by research assistants (RAs). At each facility, a local nurse or midwife was identified as facility-based focal persons. These individuals supported the recruitment process by introducing the research assistants to the participants attending the antenatal clinics. Thereafter, the RAs approached and discussed the study with individual pregnant woman. The participants, who often congregate at the antenatal clinics of the facilities for their antenatal services, were informed about the purpose and duration of the study, their responsibilities for participating in the study, ethical issues such as confidentiality, consent, anonymity and benefits of participation. Questions raised by the participants were responded to by the research team to allay fears, anxieties to encourage participation in the study.

Prior to completing the questionnaire, the participants read and signed the consent form, together with the RAs. The “broad consent” gave the research team the permission to obtain data on pregnancy outcomes and other pertinent obstetric information after delivery from the participants’ folders, where necessary. The folder/hospital identity numbers of the participants were recorded to facilitate subsequent matching of information. The questionnaires were completed individually and independently. The RAs were present to provide the needed support to the participants. Once completed, the questionnaires were handed over to the RAs. Data were collected from September 2020 to October 2020. The COVID-19 precautionary measures such as wearing of nose mask and use of alcohol-based hand sanitizers were strictly adhered to. The study received ethics clearance from the Noguchi Memorial Institute for Medical Research, University of Ghana (NMIMR-IRB CPN 057/19-20).

Data collection measures

Prodromal Questionnaire (PQ-16) was used to measure attenuated symptoms of psychosis or PLEs [19]. The PQ-16 was developed from the 92-item Prodromal Questionnaire (PQ-92) as a brief screening measure. As a self-report questionnaire, the PQ-16 screen for PLEs on a two-point scale (true/false). The PQ-16 raw scores indicate the number of PLEs a participant endorsed. The raw scores are obtained by totaling the number of true responses. The PQ-16 demonstrated good psychometric properties among patients seeking mental health care [19] and pregnant women [7].

Patient Health Questionnaire-9 (PHQ-9) is a 9-item self-report questionnaire administered to assess for depressive symptoms among the participants [20]. The PHQ-9 items are rated on a four-point Likert scale ranging from ‘not at all’ (0) to ‘nearly every day’ (3). Higher scores indicate more depressive symptoms. The internal consistency of the PHQ-9, indexed by Cronbach’s alpha, in this sample was 0.79.

Generalized Anxiety Disorder [21] scale is a 7-item scale administered to assess the symptoms of anxiety in the participants. The GAD-7 items are rated on a 4-point Likert scale, ranging from 0 (not at all) to 3 (nearly always). Total score on the GAD-7 is obtained by summing the individual items, with high scores indicating more symptoms of generalized anxiety. The Cronbach alpha of the GAD-7 was 0.85.

COVID-19 concerns

We assessed COVID-19 concerns using two items that were scored on a four-point Likert response scale from Not at all (0) to Very often (3). The first item relates to whether the participants were worried about contracting the virus and the second involved whether the participants were worried that their babies could develop some birth or developmental abnormalities should they contract the coronavirus. A total score was obtained by summing the responses, with higher scores indicating more COVID-19 concerns. A Cronbach’s Alpha of 0.92 was obtained for the two-item “COVID-19 concern” scale.

Sleep difficulty

This was measured by asking about (1) difficulty to fall asleep while in bed and (2) difficulty to stay asleep through the night. The items were extracted from the existing literature [22] and were scored using a four-point Likert response format ranging from Not at all (0) to Very often (3). Responses to each item were added to create a total score, with higher scores indicating more sleep difficulty. The Cronbach’s Alpha for the sleep difficulty scale was 0.86.

Suicidal ideation

Following a review of the literature [23], three items were extracted to index suicidal ideation as follows: Have you (1) ever thought that life wasn’t worth living; (2) ever thought about killing yourself; and (3) ever attempted to kill yourself? The response options ranged from Never (0) to Yes, several times (3).Total scores, obtained by summing the responses on the scale, ranged from 0 to 9. Higher scores reflect more suicidal ideation. The Cronbach’s Alpha for the suicidal ideation scale was 0.71.

Other factors

Intimate partner violence

This was operationalized using two items from the literature [24, 25]: (1) I have been belittled by my partner (i.e., abuse) and (2) I experienced no attention from my partner (i.e., neglect).

Help-seeking for mental health

Self-initiated help-seeking was measured with a single item: I have sought help for emotional or mental health issues while pregnant in the last 3 months. Based on the recommendations from the NICE guidelines [26], the participants responded to two items to estimate the extent to which health professionals were involved in promoting their mental well-being: (1) Nurses and midwives have asked me about my mental health or emotional well-being and (2) Nurses or midwives have offered me support such as counselling and referral for my mental health or emotional well-being needs. The response options for self-initiated help-seeking and health professional involvement were as follows: Never; Yes, once; Yes, twice and Yes, several times. These were subsequently recoded into two categories for each item: “Never” (coded 0) and “at least once” (coded 1).

Data analysis

To determine the clustering of the items on the psychosis-risk measure, we fitted principal component analysis (PCA). In addition to eigenvalue and Cattel’s scree plot criteria, the decision on the number of components to retain was also based on the results of the parallel analysis and Velicer’s Minimum Average Partial (MAP) tests [27]. Because there is no cut-off point on the PLEs measure to determine psychosis risk among pregnant women, we categorized the participants into three groups based on their PLEs scores. First, we converted the psychosis risk scores into standard (i.e., z) scores with a mean of zero and standard deviation of one. Second, scores that were 1 standard deviation below the mean were designated as no/low risk group; scores1 above the mean as high risk group and scores in between as moderate risk group. Descriptive statistics was used to determine the percentage of participants in each psychosis-risk group.

The relationship between psychosis risk group and the categorical study variables (i.e., level of education, pregnancy trimester, partner abuse, mental health help-seeking) was analyzed with chi-square (χ2). Next, a one-way multivariate analysis of variance (MANOVA) was used to determine whether the psychosis-risk groups differ significantly on the continuous study variables. A Bonferroni-adjusted univariate analysis of variance (ANOVA), with significance level at 0.01(.05/5) was used as a follow-up on the significant MANOVA results. Effect sizes were estimated with partial eta squared (η2). Prior to the MANOVA, we performed zero-order correlations using Pearson correlation coefficient to determine the correlations between the continuous variables.

Lastly, a standard multinomial logistic regression was used to predict psychosis risk group membership of the participants. The no/low risk group was used as the reference category against which the moderate and high risk groups were compared. The predictor variables were COVID-19 concerns, depressive symptoms, anxiety symptoms, suicidal ideation and sleep difficulty. The predictor variables in the multinomial logistic regression equation were standardized to mean 0, standard deviation 1 to facilitate the interpretation of the results. The data analyses were performed using SPSS Version 23 (IBM.corp) and an alpha level of 0.05, unless indicated otherwise.

Results

Demographic characteristics of participants

Participants

The participants were recruited from the various pregnancy periods (1st trimester = 63, 9%; 2nd trimester = 315, 44.9% and 3rd trimester = 324, 46.2%). More than half (n = 358, 53%) completed senior high school/equivalent (at least 12 years of education), 168 (24.9%) completed post-secondary school (additional 2 or 3 years of schooling from senior high school) whereas 22.1% (n = 149) completed university education. The average age of the participants was 30 years (SD = 5.54).

Principal component analysis

PCA was conducted to investigate the clustering of the psychosis-risk items. The Kaiser–Meyer–Olkin measure of 0.85 and Bartlett’s test of sphericity, χ2 (120) = 2750.76, p < .001 showed sampling adequacy and sufficient inter-item correlations for PCA, respectively. The eigenvalue and scree plot test suggest that two components underpin the data, whereas the results of the parallel and Velicer’s MAP test revealed one component. Given the robustness of the latter criteria [27], it was concluded that the psychosis-risk items constitute a unidimensional structure.

Prevalence and demographic correlates of psychosis risk

As shown in Table 1, of the 589 participants who responded to the psychosis risk questionnaire, 54.2% (n = 319) were classified as no/low risk for psychosis, 27.3% (n = 161) as moderate risk and 18.5% (n = 109) as high risk. In terms of the distress associated with PLEs, 44.3% reported they were not distressed, whereas 32.2% and 23.4% were a bit/quite and very distressed, respectively. Psychosis risk and distress experience were significantly correlated, (χ2 = 35.10, p < 0.001), suggesting that participants in the high risk psychosis group were more likely to report that they were distressed by the PLEs. Psychosis risk was also significantly associated with pregnancy trimester (χ2 = 14.18, p = 0.007), level of education (χ2 = 39.42, p < 0.001) experience of partner abuse (χ2 = 29.85, p < 0.001) and help-seeking for mental health (p < 0.001).

Table 1

Chi square results of the correlation between psychosis risk group and categorical variables.

Variables	Psychosis risk			Statistics
	No/low	Moderate	High	Chi square	P-value
Trimester				14.18	0.007
First	26(8.2)	19(11.8)	170(9.2)
Second	123(38.6)	83(51.6)	59(50.5)
Third	170(53.3)	59(36.6)	44(40.4)
Education				39.42	0.000
SHS/Equivalence	133(43.5)	98(62)	62(60.2)
Diploma	76(24.8)	42(26.6)	32(31.1)
Degree	97(31.7)	18(11.4)	9(8.7)
Partner Abuse				29.85	0.000
No	234(74.8)	85(53.5)	56(52.3)
Yes	79(25.2)	74(46.5)	51(47.7)
Distress				195.81	0.000
No	210(69.1)	22(14.6)	15(14.2)
A bit/quite	74(24.3)	65(43)	37(34.9)
Very	20(6.6)	64(42.4)	54(50.9)
Self-Initiated Help-Seeking				58.04	0.000
No	290(92.1)	119(74.8)	66(61.1)
Yes	25(7.9)	40(25.2)	42(38.9)
Being Asked				34.47	0.000
No	143(45.4)	39(24.4)	21(19.4)
Yes	172(54.6)	121(75.6)	87(80.6)
Offered Support				59.27	0.000
No	206(66.2)	58(36.3)	34(31.5)
Yes	105(33.8)	102(63.7)	74(68.5)

MANOVA results of group differences on dependent variables

The intercorrelations between the study variables were summarized in Table 2. With respect to Table 1, except for suicidal ideation and COVID-19 concerns, the study variables were significantly and positively correlated (p < 0.01). The results from the MANOVA revealed that the multivariate effect of psychosis risk group membership was statistically significant, Wilk’s lambda = .700, F (10, 1020) = 19.86, p < 0.001, η2 = .16. The univariate F ratios and eta squared values together with the means and standard deviations of the groups for each dependent variable are shown in Table 3. The eta squared values ranges from 0.10 to 0.15. The groups differ significantly on all the dependent variables (p < .001). A Bonferroni post hoc test, applied to the dependent variables showed that the moderate and high-risk psychosis groups reported significantly greater COVID-19 concerns, depressive and anxiety symptoms, suicidal ideation and sleep difficulty than the No/Low risk group. The moderate and high-risk groups differ significantly only on sleep difficulty, with the high-risk psychosis group reporting more sleep difficulty than the moderate risk group.

Table 2

Intercorrelation and descriptive statistics of continuous study variables.

	1	2	3	4	5	6
1. Psychosis Risk	1
2. COVID-19 Concerns	0.39*	1
3. Depressive Symptoms	0.36*	0.38*	1
4. Anxiety Symptoms	0.38*	0.41*	0.71*	1
5. Suicidal Ideation	0.32*	0.05	0.21*	0.19*	1
6. Sleep Difficulty	0.41*	0.47*	0.41*	0.45*	.17*	1
M	5.60	4.62	14.83	12.30	3.69	4.31
SD	3.98	2.23	4.46	4.42	1.36	1.64
Minimum	0	2	9	6	3	2
Maximum	16	8	36	28	12	8
Cronbach’s Alpha (α)	.83	.92	.79	.85	.71	.86

* Correlation is significant at the 0.01 level (2-tailed).

Table 3

ANOVA (F) ratios, means and standard deviations of the no/low, moderate and high risk groups on the study variables.

			No/Low risk (n = 280)		Moderate (n = 140)		High risk (n = 96)
Variables	F(1, 513)	η2	M	SD	M	SD	M	SD
COVID-19 Concerns	45.55*	0.15	4.00	2.00	5.48	2.28	6.07	2.10
Depressive Symptoms	43.02*	0.14	13.30	3.58	16.80	4.44	16.35	4.72
Anxiety symptoms	35.36*	0.12	10.95	3.90	13.77	4.42	14.31	4.27
Suicidal Ideation	28.08*	0.10	3.25	.82	3.99	1.67	4.17	1.56
Sleep Difficulty	44.10*	0.15	3.8	1.38	4.75	1.67	5.40	1.79

* = p < .001; η2 = partial eta squared; M = Mean and SD = Standard deviations.

Predicting psychosis risk group membership

The results of the multinomial logistic regression revealed that the model containing the predictors was significantly different from the intercept-only model, χ2 (10, n = 516) = 175.96, p < 0.001. Using the deviance criterion, the model provided a good fit to the data, χ2 (858, n = 516) = 782. 24, p = .969. The predictors explained 33.3% of the variance in the psychosis-risk group membership (Nagelkerke R = .33). Prediction success for group membership was modest, with an overall rate of 60.5%, and correct prediction rates of 88.2%, 29.3% and 25% for no/low, moderate and high-risk groups, respectively. The unique contribution of the predictors in the multinomial logistic regression is summarized in Table 4. All but anxiety symptoms independently contributed to the significance of the regression model (all ps < .05). The result evaluating the influence of the predictors (Table 5) showed that COVID-19 concerns, depressive symptoms and suicidal ideation were significant predictors of moderate risk for psychosis. More precisely, participants who expressed concerns relating to COVID-19, scored high on depressive symptoms and suicidal ideation were 1.60 (CI = 1.236 ‒ 2.076), 1.82 (CI = 1.295 ‒ 2.549) and 1.93 (CI = 1.453 ‒ 2.566) times more likely to be in the moderate risk for psychosis group, respectively.

Table 4

Predictors’ unique contributions in the multinomial logistic regression (n = 516).

Predictor	χ2-test	df	p
COVID-19 Concerns	23.06	2	< 0.001
Depressive Symptoms	13.02	2	0.001
Anxiety symptoms	1.08	2	.581
Suicidal Ideation	33.89	2	< 0.001
Sleep Difficulty	10.32	2	0.006

Table 5

Parameter estimates contrasting the no/low risk psychosis group versus moderate and high risk groups (n = 516).

Model	B	SE-B	Wald	Ex(B)	95% CI for Ex(B)
Moderate Risk
Intercept
COVID-19 Concerns	0.47	0.12	28.76**	1.60	1.236 ‒ 2.076
Depressive Symptoms	0.60	0.13	12.69*	1.82	1.295 ‒ 2.549
Anxiety Symptoms	0.01	0.17	0.01	1.00	.726 ‒ 1.398
Suicidal Ideation	0.66	0.15	20.57**	1.93	1.453 ‒ 2.566
Sleep Difficulty	0.18	0.14	1.61	1.20	.908 ‒ 1.573
High Risk
Intercept
COVID-19 Concerns	0.67	0.16	18.22**	1.95	1.437 ‒ 2.659
Depressive Symptoms	0.24	0.20	1.41	1.27	0.858 ‒1.872
Anxiety Symptoms	0.18	0.19	0.90	1.20	0.823 ‒ 1.748
Suicidal Ideation	0.77	0.15	24.95**	2.16	1.598 ‒2.928
Sleep Difficulty	0.50	0.16	10.03*	1.65	1.209 ‒ 2.238

Note: The dependent variable was psychosis risk groups with no/low psychosis risk group as the reference category.

Degree of freedom (df) = 1; Ex(B) = odd ratios; SE-B = Standard error of B.

* = p < .01

** = p < .001.

Participants who expressed suicidal ideation and concerns relating to COVID-19 were 1.96 (CI = 1.437 ‒ 2.659) and 2.16 (CI = 1.598 ‒ 2.928) times more likely to be classified into high risk for psychosis group, respectively. In this model, sleep difficulty also emerged as a statistically significant predictor; participants who reported sleep difficulty were 1.65 (CI = 1.209 ‒ 2.238) more likely to be in the high risk for psychosis group. From the foregoing, the most consistent predictors of moderate and high-risk group membership were COVID-19 concerns and suicidal ideation.

Discussions

Understanding psychosis risk in pregnancy will improve decision making in maternal mental health care. In this study, 18.5% of the participants were classified as high risk for psychosis, whereas 27.3% fell into the moderate risk group. Although data-driven, the validity of the psychosis risk group is partly proven by the ANOVA and post-hoc analyses results that showed that participants in the high or moderate group significantly endorsed the risk factors of poor perinatal mental health than those in the low-risk group. The 18.5 to 27.3% psychosis risk found in this study is similar to the 27% psychosis risk prevalence rate recorded among pregnant women in Peru [7].

Psychosis risk is notably elevated among pregnant women who were more concerned about the COVID-19 effects as well as expressed suicidal ideation. That is, the above risk factors separated pregnant women classified as low/no risk from those categorized as moderate and high risk for psychosis. The findings relating to COVID-19 and elevated scores on psychosis risk is in tandem with the existing literature that suggest that COVID-19 significantly affects the mental health and wellbeing of pregnant and postpartum women. Reviews conducted on COVID-19 and perinatal mental health have found that pregnant and postpartum women endorsed more symptoms of anxiety and depression during the COVID-19 pandemic compared with the previous non-pandemic times [28-30]. While the exact mechanism underlying this finding has not been explored in this study, it is posited that the decrease in access to mental health support services such as professionals and social networks occasioned by the COVID-19 mitigation measures could be implicated [28]. The enforcement of COVID-19 mitigation measures, notably lockdowns resulted in limited behavioral practices such as physical activity or exercises that serve as protective factors against mental health problems.

The connection between psychosis risk and suicidal ideation has long been established in related literature among non-pregnant and postpartum women [31-33]. Several mechanisms of action have been proposed, including the view that command hallucination in psychosis promotes suicidal ideations. Others have also maintained that individuals at risk for psychosis tend to manifest severe and multi-comorbid psychopathologies such as depression and anxiety [31]. The cumulative effect of the psychopathologies may increase the risk for suicidal tendencies. The findings reported in this study further attest to the robustness of the relationship between psychosis risk and suicidal tendencies, providing additional layer of evidence on the need to pay critical attention to psychosis risk in pregnancy.

Depressive tendencies and sleep difficulties are among the most widely reported mental health problems experienced by pregnant women [34, 35]. In non-pregnant population, studies have established a relationship between psychosis risk and depression symptoms [36]. The current study has extended the existing literature by demonstrating a positive association between psychosis risk, depressive symptoms and sleep difficulties. Depressive symptoms and sleep difficulties were significantly endorsed by participants who were classified as moderate and severe risk for psychosis, compared with those at low risk. Depressive symptoms have been identified as forming an essential component of the prodrome of schizophrenia [36]. By extension, depressive symptoms can be expressed by a person at high risk for psychosis. This is partly because the distress and other behavioral changes associated with the experiences of psychotic like symptoms such as hallucination and delusions can promote depressive feelings.

Limitations

The study findings should be evaluated considering the following limitations. The cross-sectional design adopted in this study does not permit commentaries on causal relationship. The recruitment of participants with at least senior high school education for the study implies that the findings may not be applicable to those with less formal education. The findings could have been different with equal or similar number of pregnant women across the three trimesters. The use of convenience sampling increases the risk of selection bias. Lastly, although single or few-item measures are capable of representing complex variables, multiple-item questionnaires are known to have superior psychometric properties, which could have influenced the findings reported here [37, 38].

Conclusions

The study has provided initial evidence regarding the prevalence of PLEs in pregnancy in a Western Africa country, Ghana. It is envisaged that the findings will serve as a wake-up call for researchers to investigate PLEs and psychosis in the perinatal period as a public health issue. Healthcare professionals should equally consider to include PLEs screening measures into the existing gamut of mental health screening tools used in the perinatal period. Once screened, education and awareness creation on psychosis and psychosis-risk should be undertaken to increase the knowledge-base of pregnant women. Information on the characteristics, manifestation of psychotic-like symptoms, the transition to full-blown psychotic disorders and negative impacts of psychosis on pregnancy and pregnancy outcomes should be incorporated into the education and awareness program. It is recommended that future studies are conducted to unearth the nature or mechanisms as well as the risk and protective factors of the trajectory of PLEs to clinically diagnosable psychosis.

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16 Aug 2021

PONE-D-21-20182

Psychosis Risk among Pregnant Women in Ghana

PLOS ONE

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors, this is an interesting article about mental health of pregnant women. I quote below my suggestions to your manuscript.

a. Specify the exact number of the original sample and that of the final sample. It is not understood

b. The duration of the study is not mentioned in the methodology

c. How was the sample approached? Was it done during the standard check-up or during hospitalization?

d. The week of pregnancy is not specified

e. In the Introduction section describe what are the (PLEs) symptoms. In addition, for which mental disorders these symptoms are risk factors

f. Specify what the (PLEs) symptoms include in the results (eg what the anxiety symptoms include)

g. The psychometric scales are not presented in a table

h. The conclusions are not supported by the results

i.Please reconsider your definition(s) in the article

Example: Psychotic-like experiences (PLEs) are subtle, subclinical hallucinations and delusions which are quite common in general population*

Please reconsider your conclusion in the article

Example: The risk of developing a severe mental illness in pregnancy is estimated to be 7.1 in 10,000 per year. New-onset acute psychosis during pregnancy is extremely rare**

*Remberk B. Clinical significance of psychotic-like experiences in children and adolescents. Psychiatr Pol 2017, 51:271-82.

**Watkins ME, Newport J. Psychosis in Pregnancy. Obstetrics & Gynecology 2009, 113: 1349.

Reviewer #2: This paper uses a cross-sectional design to investigate risk factors during pregnancy for postpartum psychosis (PPP). It adds to an important area of the perinatal mental health literature, as PPP is the most severe mental illness in the perinatal period and not many studies have investigated psychotic-like experiences during pregnancy as a risk factor for PPP. A strength of the study is the large sample size the authors obtained data from.

I have divided my comments into major and minor points.

Major:

1. This study feels incomplete without following up with women in the postpartum period to understand who went on to develop PPP within the sample. Given that the study examined risk factors/correlates of psychotic-like experiences in pregnancy, and PLEs can be a starting point of PPP, it would be helpful to know whether those women who scored high on the PQ-16 questionnaire and had identified correlates (depression, suicidal ideation, COVID-19 anxiety, sleep disturbances) actually developed PPP symptoms in the end. This way we can understand whether 1) the identified correlates may in themselves be risk factors for PPP, and 2) the PQ-16 questionnaire is a valid predictor of PPP in itself. Furthermore, it would help the authors to determine whether a cut-off score can be used on the PQ-16 to identify pregnant women at greatest risk.

2. Please discuss why the authors chose not to include participants with a history of mental health disorder/current mental health disorder as these are one of the biggest risk factors for PPP? Especially given that it was found that main correlates of high PLE scores were depressive and anxious symptoms and suicidal ideation, it would be important to understand whether pregnant women with histories of (or current) mental illness score highly on the PQ-16.

3. It would be beneficial to analyse more variables in the study variables list, such as socioeconomic status, social support, marital status, perceived stress, history of childhood maltreatment, i.e. further risk factors for PLEs and PPP.

4. With regard to the questions on suicidal ideation and intimate partner violence, please state whether a factor analysis was completed to determine that these items are valid extractions of an entire questionnaire.

5. Given that there was multicollinearity between many of the variables in Table 2, they should not have all been entered into a regression together.

Minor:

1. In the introduction, please discuss PPP prevalence across more societies/cultures than only the US and Sweden, as both are high-income countries.

2. Please discuss whether the PQ-16 has been previously validated as a predictor of PPP in a perinatal sample, rather than a predictor of psychosis in a general sample.

3. Related to point 2, please discuss whether the PQ-16 has been validated across various cultures and ethnicities.

4. Please reference Hazelgrove et al. (2021)’s paper on risk factors for postpartum psychosis.

5. Table 1: please indicate where the group-differences are in the chi-square and please indicate whether the values are listed as number (%) or %(number).

6. In addition to asking women whether they were concerned about COVID-19, were they also asked whether they had contracted the virus? This is especially important as COVID-19 has been found to cause psychotic-like symptoms in some patients.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

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Submitted filename: The study presents the results of original research.docx

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22 Oct 2021

Psychosis Risk among Pregnant Women in Ghana

PONE-D-21-20182

RESPONSE FROM AUTHORS: We have noted our responses to the reviewers’ comments below in yellow highlight. We appreciate the feedback from the reviewers.

Reviewer 1 Comments

Dear authors, this is an interesting article about mental health of pregnant women. I quote below my suggestions to your manuscript.

a. Specify the exact number of the original sample and that of the final sample. It is not understood.

Authors’ response: A total of 702 women were recruited for the study but some were missing data on some study variables. Excluding participants with missing data in the analyses caused a reduction in the sample size across.

b. The duration of the study is not mentioned in the methodology

Authors’ response: This has been specified as follows: “Data were collected from September to October 2020”

c. How was the sample approached? Was it done during the standard check-up or during hospitalization?

Authors’ response: We have included this information in the revised manuscript as follows: “The participants, who often congregate at the antenatal clinics of the facilities for their antenatal services, were informed about the purpose and duration of the study, their responsibilities for participating in the study, ethical issues such as confidentiality, consent, anonymity and benefits of participation.” (page 6).

d. The week of pregnancy is not specified

Authors’ response: We included data on the weeks of pregnancy as follows: “Pregnant women in their first (≤ 12 weeks of pregnancy), second (≤ 24 weeks of pregnancy) or third trimesters (≤ 36 weeks of pregnancy) were recruited for the study.” (page 6).

e. In the Introduction section describe what are the (PLEs) symptoms. In addition, for which mental disorders these symptoms are risk factors

Authors’ response: A brief description of PLEs is provided. The section now reads:

“PLEs are very common in the general population, appearing first in adolescence and sometimes in childhood (Zavos et al., 2014) and can be categorized as positive (e.g., perceptual abnormalities, delusional thoughts) or negative (e.g., social withdrawal, avolition) (Yung et al., 2009). Among the common examples of the PLEs are hearing voices, seeing things, and smelling things that other people do not hear, see or smell, respectively.” (page 4).

f. The psychometric scales are not presented in a table

Authors’ response: In table 2, we provided data on the Cronbach alpha for all the scales used in the study.

g. The conclusions are not supported by the results

Authors’ response: We have revised the conclusion section of the manuscript accordingly.

Please reconsider your definition(s) in the article

Example: Psychotic-like experiences (PLEs) are subtle, subclinical hallucinations and delusions which are quite common in general population*

Authors’ response: We have expanded on the initial definition provided in the manuscript. The section now reads:

“PLEs are subclinical symptoms of psychosis that do not meet the threshold for clinical diagnosis as psychotic illness (Fusar-Poli et al., 2012; Hielscher et al., 2018). PLEs are very common in the general population, appearing first in adolescence and sometimes in childhood (Zavos et al., 2014) and can be categorized as positive (e.g., perceptual abnormalities, delusional thoughts) or negative (e.g., social withdrawal, avolition) (Yung et al., 2009). Among the common examples of the PLEs are hearing voices, seeing things, and smelling things that other people do not hear, see or smell, respectively.” (page 4).

*Remberk B. Clinical significance of psychotic-like experiences in children and adolescents. Psychiatr Pol 2017, 51:271-82.

**Watkins ME, Newport J. Psychosis in Pregnancy. Obstetrics & Gynecology 2009, 113: 1349.

Authors’ response: Thank you very much for these articles. They are extremely helpful.

Reviewer #2: This paper uses a cross-sectional design to investigate risk factors during pregnancy for postpartum psychosis (PPP). It adds to an important area of the perinatal mental health literature, as PPP is the most severe mental illness in the perinatal period and not many studies have investigated psychotic-like experiences during pregnancy as a risk factor for PPP. A strength of the study is the large sample size the authors obtained data from.

I have divided my comments into major and minor points.

Major:

1. This study feels incomplete without following up with women in the postpartum period to understand who went on to develop PPP within the sample. Given that the study examined risk factors/correlates of psychotic-like experiences in pregnancy, and PLEs can be a starting point of PPP, it would be helpful to know whether those women who scored high on the PQ-16 questionnaire and had identified correlates (depression, suicidal ideation, COVID-19 anxiety, sleep disturbances) actually developed PPP symptoms in the end. This way we can understand whether 1) the identified correlates may in themselves be risk factors for PPP, and 2) the PQ-16 questionnaire is a valid predictor of PPP in itself. Furthermore, it would help the authors to determine whether a cut-off score can be used on the PQ-16 to identify pregnant women at greatest risk.

Authors’ response: It is true that following up on the participants after delivery to determine those diagnosed with psychosis would add significantly to the findings of the study. Our main goal in this study was to determine the prevalence of psychotic like experiences (PLEs). Individuals scoring high on PLEs are at risk for psychotic illness and not necessarily that they would develop psychotic illness. Therefore, it is possible that none of the participants would have been diagnosed with psychotic illness at follow-up. The discussion would have been different if we had screened for psychosis as a mental disorder. In view of this, we are happy to contribute to the emerging literature on the prevalence and correlates of PLEs among pregnant women in Ghana. We are optimistic that the findings will serve the research community in terms of opening up future research areas.

2. Please discuss why the authors chose not to include participants with a history of mental health disorder/current mental health disorder as these are one of the biggest risk factors for PPP? Especially given that it was found that main correlates of high PLE scores were depressive and anxious symptoms and suicidal ideation, it would be important to understand whether pregnant women with histories of (or current) mental illness score highly on the PQ-16.

Authors’ response: We initially collected data on individuals with a history of mental disorders (n = 5). However, our initial analyses reveal that they scored very high on the measures of anxiety and depression etc, emerging as outliers. To maintain sample purity, we agreed to exclude them. If their numbers were high, we could have compare them with those without diagnoses of mental disorders.

3. With regard to the questions on suicidal ideation and intimate partner violence, please state whether a factor analysis was completed to determine that these items are valid extractions of an entire questionnaire.

Authors response: Thank you for the observation. Yes, we subjected the items measuring suicidal ideation and IPV to principal component analysis. We requested for one component given the small number of items. All the items loaded satisfactory on the component, with correlation coefficients ranging from .52 to.89. Based on PCA, we treated the added the items measuring suicidal ideation and IPV to obtain unidimensional scores that were used for the analyses

4. Given that there was multicollinearity between many of the variables in Table 2, they should not have all been entered into a regression together.

Authors’ response: We observed a correlation of .71 between anxiety and depressive symptoms. Other correlations ranged from .19 to 41, which are normal for regression analysis. The correlation coefficient of .71 appear high but there was no evidence of multicollinearity in the regression analysis.

Minor:

1. In the introduction, please discuss PPP prevalence across more societies/cultures than only the US and Sweden, as both are high-income countries.

Authors’ response: Thank you for the observation. Unfortunately, data is limited from other context. In a South African we have referenced in the revised manuscript, there was no information on prevalence. Rather, data were collected from individuals diagnosed with PPP. We have noted this in the revised manuscript (page 3).

2. Please discuss whether the PQ-16 has been previously validated as a predictor of PPP in a perinatal sample, rather than a predictor of psychosis in a general sample.

Authors’ response: The PQ-16 has been validated to screen for psychotic-like experiences in the general population (Ising et al., 2012) and pregnant women (Levey et al., 2018).

3. Related to point 2, please discuss whether the PQ-16 has been validated across various cultures and ethnicities.

Authors’ response: With respect to pregnant women, the PQ-16 has been validated in Peruvian pregnant women (Levey et al., 2018) only.

4. Please reference Hazelgrove et al. (2021)’s paper on risk factors for postpartum psychosis.

Authors’ response: Thank you very much. The reference has been included in the revised manuscript.

5. Table 1: Please indicate whether the values are listed as number (%) or %(number).

Authors’ response: We have indicated in the revised manuscript that the figures in the bracket represent percentages.

6. In addition to asking women whether they were concerned about COVID-19, were they also asked whether they had contracted the virus? This is especially important as COVID-19 has been found to cause psychotic-like symptoms in some patients.

Authors’ response: We did not ask the participants whether they contracted the virus. This is an excellent observation that would be incorporated into our future work.

Submitted filename: Response to Reviewer comments.docx

Click here for additional data file.

16 Nov 2021

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PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Author, I quote below some points about your article

• Abstract: Perinatal psychosis is a very rare and not a common illness

• Introduction: It is important to mention at this point the risk factors for developing psychosis, such as bipolar disorder, family history, atomic history of psychotic episode etc.

• It would be better to summarize the psychometric tools

• Also, the history of the woman's mental illness has not been studied, social support or not, if pregnancy was desired, if there was pregnancy pathology…

• As for Covid, is there any information on whether women were exposed to the virus or not?

• In the conclusions, what interventions do you suggest to perinatal health care professionals regarding the early recognition of psychotic symptoms? What do you suggest to improve this situation?

• What measures should be taken to prevent further development of the disorder in postpartum period?

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

20 Nov 2021

Psychosis Risk among Pregnant Women in Ghana

PONE-D-21-20182R1

RESPONSE FROM AUTHORS: We have noted our responses to the reviewers’ comments below in yellow highlight. We appreciate the feedback from the reviewers.

Reviewer Comment 1: Abstract: Perinatal psychosis is a very rare and not a common illness

Response: The statement has been revised as follows;

“Psychotic illness, although is rare, has been reported in the perinatal period.”

Reviewer Comment 2: Introduction: It is important to mention at this point the risk factors for developing psychosis, such as bipolar disorder, family history, atomic history of psychotic episode etc.

Authors’ response: Thank you. We have included in the manuscript risk factors culled from the perinatal factors as follows;

As a heterogeneous mental disorder, several risk factors have been documented, including childhood maltreatment (Hazelgrove et al., 2021), low socio-economic status, neighborhood level social deprivation (Radua et al., 2018). Among the perinatal factors implicated in psychosis include diabetes in pregnancy, antepartum haemorrhage, preeclampsia, maternal stress during pregnancy, pre-pregnancy and pregnancy maternal obesity and cord complications (Radua et al., 2018).

Reviewer Comment 3: It would be better to summarize the psychometric tools

Authors’ response: Thank you very much. We are not what you meant by summarize the psychometric tools. This study is not a validation study and so detailed psychometric properties was not presented. As much as possible, we presented the reliability of the questionnaires that are not categorical. This was done for each measure as far as practicable.

Reviewer Comment 4: As for Covid, is there any information on whether women were exposed to the virus or not?

Authors’ response: Thank you. We are not aware of the exposure status of the women who took part in the study. We can only deduce that since they were not recruited from isolation centers, or their medical records did not contain evidence of COVID-19, they probably did not contract COVID-19.

Reviewer Comment 5: In the conclusions, what interventions do you suggest to perinatal health care professionals regarding the early recognition of psychotic symptoms? What do you suggest to improve this situation?

Authors’ response: Thank you very much. We noted in the manuscript that this is one of the initial studies exploring psychotic-like-experiences in pregnancy. Therefore, we are careful to state the usefulness of the findings to healthcare delivery. At this stage, we can only recommend, as stated in the manuscript (conclusion section) that screening for psychotic-like experiences should be incorporated into the existing perinatal care services with the hope of picking at risk women for early intervention.

Reviewer Comment 6: What measures should be taken to prevent further development of the disorder in postpartum period?

Response: This is a very important question. Unfortunately, we could not follow the participants from pregnancy to post-delivery periods to know the rate of conversion to full-blown psychosis. Therefore, we could not comment on measures to prevent the development of psychosis in the postpartum period.

Submitted filename: Response to reviewer comments 2.docx

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3 Dec 2021

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Frank T. Spradley

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Authors,

You have made enough effort to improve the article. However, some difficult points remain unclear

• With regard to the scales of measurement, I referred to the possibility of presenting them in less detail

• Furthermore, even if a study is in its early stages clear conclusions from the study need to be presented. The conclusions also include the authors' suggestions as well as any interventions required

• In addition to identifying a significant mental health problem in the postpartum period, researchers should be able to come up with some preventative measures to reduce them. For example, identifying risk factors from pregnancy or early postpartum period, educating perinatal health care professionals on recognizing dangerous symptoms, educating the family on caring for women with mental disorders and others….

Regards

**********

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Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.