Title: Postpartum depression in Vietnam: A scoping review of symptoms, consequences, and
management
Version: 6 Date: 28 Apr 2023
Reviewer's report:
Overall, the manuscript is much improved with the removal of the clustering theme.
I have reviewed the responses to my previous review and find most issues have been addressed
adequately. I must disagree that stigma only plays a minor role in identification of postpartum
depression symptoms. Identification involves disclosure, which is heavily influenced by
silencing about mental health issues. However, that is not the main focus of this manuscript.
However, there are still some issues that require attention:
• The authors continue to use a confusing definition of the term postpartum depression (including
the blues and psychosis). I reviewed the references that they cite for their definitions. These
references do not support the use of the term “blues” nor the inclusion of psychosis. Their
definition requires further consideration and be revised to be more consistent with the references
they used.
If they wish to acknowledge the much less common but more serious postpartum psychotic
depression or postpartum psychosis, then perhaps they could dedicate a section on this in their
results section.
I checked the cited references::
reference #1 – Miller (2002) separates postpartum non-psychotic depression and postpartum
psychotic depression. The prevalence rates are usually in relation to non-psychotic depression.
Reference #2 (which should be updated to the latest version of the DSM)
DSM-IV-TR does not recognize postpartum depression as a separate diagnosis; rather, patients
must meet the criteria for a major depressive episode and the criteria for the peripartum-onset
specifier. The definition is therefore a major depressive episode with an onset in pregnancy or
within 4 weeks of delivery.
Much criticism has been raised about the onset having to be within 4 weeks. Current articles
extend this criterion, ranging from 4 to 6 weeks postpartum to up to 1 year.
Reference #3
Stewart et al (2003). Her article specifically refers to non-psychotic depression.
• It would be helpful if information was provided as to nurses’ roles in the current provision of
postpartum care in Vietnam. Do they operate in public health clinics that provide such care? This
information would help contextualize this article and support nurses being in a strong position
to identify emerging symptoms of PPD.
• Line 63 -  Focus of the 2 cited references was on risk factors and prevalence in India and
Turkey – focus was not on prevention.
• Line 64 -  phrase “not well concerned is grammatically awkward/incorrect and not clear on
its meaning.
• Line 75 – phrase “literately synthesized” is also grammatically awkward and incorrect and not
clear on its meaning.
• Line 171 – “PPD was known to self-resolve in most mild cases with appropriate health
care. This statement needs to be further explained and supported with evidence and relevant
references. What would be the appropriate health care? With often limited health care resources,
the appropriate use of scarce resources becomes an important issue. For example, if universal
screening done too early, seems intervention for most would not be necessary. Screening at 6-8
weeks might be more clinically useful. With comprehensive antepartum history taking which
would identify those at higher risk for PPD, women with higher risk could then be set up for early
and ongoing contacts with health professionals. Some information about the Vietnam health
services system and availability of resources would be helpful here.
• Line 173 – clarify what is meant by “this fragile period”, if most mild cases self-resolve, what
is the fragile period referred to in this sentence.
• Line 189 - This paragraph seems out of sync with the earlier statement that PPD often self-
resolves. Further exploration of how to identify those that are likely to self-resolve and those
that require ongoing contacts would be more helpful and economically viable. The suggestion
that all women should be assessed during the first days postpartum might be unnecessary in the
face of limited health resources.
• Line 213-214 reference #2 is the DSM IV not DSM IV-TR or the most recent V
• Line 224 – the statement that “According to the definition of PPD, PP blues can disappear is
inconsistent with line 171, which states it is mild PPD that self-resolves. PP blues is not part
of the definition of PPD.
• Line 234 – The statement that “Professional care is in high demand” in Vietnam is inconsistent
with the text in lines 173-176.