Title: Women’s experiences of psychological treatment and psychosocial interventions for
postpartum depression: A qualitative systematic review and meta-synthesis
Version: 1 Date: 06 Sep 2023
Reviewer:  Kenneth Finlayson
Reviewer's report:
This is a very interesting and well conducted qualitative synthesis of the topic area and contains
some useful insights for policy makers, practitioners and researchers. I just have a few comments
and queries which the authors may like to consider:-
1. I note that the current synthesis is very similar to a previous synthesis in this area (Hadfield
& Wittkowski, 2017) and although the authors identify this study and refer to it throughout,
I'm unclear as to why the authors felt it was appropriate to conduct another synthesis given the
inherent similarities. The authors briefly mention that "The aim of the current review was to
provide an updated and comprehensive understanding of women’s experiences of psychological
interventions for postpartum depression" but don't distinguish how or if the current synthesis
differs. If it's an update then I would only expect searches to be conducted from 2016/17 (to
include new data) but if there are distinct differences then there should be an explanation in the
introduction - especially so given that the Hadfield synthesis included 17 articles and this one
includes 8.
2. As a follow up question it would be interesting to know a little more about  the 'SBU Quality
assessment tool'  given that 10 studies were excluded on quality (risk of bias) grounds. I'm
guessing most readers won't be familiar with this tool so a few details about the components
would aid understanding.
3. On page 4 only 5 databases (missing SCOPUS?) are listed but elsewhere the authors refer to 6.
4. On table 1 (exclusion criteria ) a criterion listed as "Studies not relevant to the Swedish
context" seems a bit vague to anyone unfamiliar with the Swedish context. Would it be more
explicit to state 'studies conducted in high-income countries' or something similar?
5. On page 5 the authors state that   "70 articles were assessed in full-text, and yielded a final
sample of eight studies for data extraction.....". For clarity, it might be better to state that '8
studies were included for data extraction' - the use of the word 'sample' suggests something
different, i.e. that studies were sampled rather than chosen.
6. Furthermore, on the PRISMA flowchart it would further aid understanding if the (broad)
reasons for the exclusion  of 52 studies were listed - in accord with common practice in PRISMA
flowcharts.
7. I note that the authors use thematic synthesis (Thomas & Harden, 2008) as the synthesis
method  but then refer to 'Level 1' and 'Level 2' findings? Again, to aid clarity and understanding,
it would be useful if the authors referred to the terminology adopted by Thomas and Harden,
i.e. descriptive themes and analytical themes. In this case I assume Level 1 themes refer to
descriptive themes and Level 2 to analytical themes?
8. Similarly, if the use of the CERQual tool is being used to express confidence in the findings
then I would expect to see the terminology of CERQual being used. So the symbols in the last
column of table 3 should be replaced with the appropriate CERQual grades, i.e. High, Moderate,
Low or Very Low.
In addition, to aid clarity and transparency, it would be useful if the authors could provide either
an additional table or appendix to show how each descriptive theme was graded according to
the four CERQual components.
9. On page 20 the authors state that " In the synthesis by Megnin-Viggars et al. (2015) women
emphasized continuity of care,  as important for being able to disclose symptoms of depression".
By 'continuity of care' does the review mean during the maternity phase generally (as a model of
care) or continuity of care for the treatment of depressive symptoms, i.e. by the same therapist?
10. Finally,  the discussion section seems a little narrow and I wonder if the authors might like
to consider some of the literature relating to the effectiveness of different interventions....to
appreciate the full picture. For example, interventions may be effective but acceptability or
feasibility considerations limit implementation, e.g group therapy may be effective but some
women may not like it because it lacks privacy, etc;. Furthermore the authors indicate that
treatments (interventions) should be individualized which raises implementation and resource
implications. How might these challenges (and others) be addressed in a practical sense. A
broader discussion (word count permitting!) might enhance the relevance of this study and give
the conclusion, in both the narrative and the abstract, a bit more 'bite'!