Reviewer ’s report  
 
Title: Correlates of depressive symptoms in late middle -aged Taiwanese women: Findings fro m 
the 2009 Taiwan National Health Interview Survey  
 
Version: 1 Date: 16 Nov 2015  
 
Reviewer: Amanda Deeks  
 
Reviewer's report:  
 
This is a study that considered diabetes and depressive symptoms in  postmenopausal women.  A 
number of previous studies have established higher rates of depressive symptoms in men and 
women with diabetes.  The authors are correct that there is less known about the association with 
menopause.  
Unfortunately the authors focu s more on diabetes and depressive symptoms and our 
understanding of the experience in postmenopause is not really confirmed or discussed fully in 
the current manuscript: there is just not enough of aan argument as to why menopause has been 
included and sad ly, this is a missed opportunity.   
 
The authors fail to establish how menopausal status was confirmed. What questions were asked 
to confirm menopause, were women on HRT or women who had a surgical menopause 
included? These are all factors likely to impact  on the experience of depression.  The only 
reference to menopausal status was on page 6, Line 14  "In addition, women (n=31) who still had 
regular menstruation at the time of the survey interview were excluded."  What about women 
who had irregular menstru ation who were likely to be perimenopausal? Perimenopause is known 
to be a time of hormonal swings and this increases mood swings, depressive and anxious 
symptoms. Not including a definition or reference to the methodology to determine menopausal 
status is  a major flaw and disappointing given that the study was "investigating the association 
between diabetes and depressive symptoms in postmenopausal Taiwanese women…"  It would 
be better to delete references to postmenopause and instead focus on age.  
 
One o f the few references to the impact menopause may have on depression is on page 4 Line 
33-39.  The authors refer to a paper by Soares 2013 and state that …"the changes in sex hormone 
profile and the dysregulation of the hypothalamic -pituitary -adrenal (HPA) axis associated with 
menopause may also contributed to an increased risk of depression in women."  This is 
misleading.  The issue of depression and menopause is very complex which is discussed by 
Soares and more likely in women who have a sudden withdrawal  of hormones as in women who 
have had a surgical menopause.  As this is one of the few references to menopause and 
depression the authors have missed an opportunity to explore the complexity of this issue.   
 
There is also little reference made to diabetes  and menopause and yet there have been a number 
of studies that have explored this previously such as the increased risk in postmenopause due to 
changes in adiposity and the metabolic profile.  
 
Menopause status, depression and diabetes is a complex area of  investigation and is worthy of 
further understanding.  I am not sure the authors can conclude given this was a cross -sectional 
study based entirely on self -report that menopause and diabetes "…can increase the risk of 
depressive symptoms in women." Page 1 3, line 4 -7.  It is a much more complex story than 
currently discussed in this paper.  
 
If the authors change the focus to be about age or include more fully the discussion of how 
menopause was established and the complexity of its role in depression then this paper would be 
improved.  
 
Are the methods appropriate and well described?  
If no t, please specify what is required in your comments to the authors.  
 
No 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by t he data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, ple ase specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some languag e corrections before being published  
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publi cation of this  
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financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you curr ently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
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