Title: Menstrual cycle related depressive symptoms and their diurnal fluctuations – an
ambulatory assessment study
Version: 3 Date: 04 Jul 2024
Reviewer's report:
“Menstrual cycle related depressive symptoms and their diurnal fluctuations – a ambulatory
assessment study” is a useful, sound investigation of how depressive symptoms fluctuate within
a day and within individuals over a menstrual cycle. The findings of this paper will be useful
for practice and further research. However, I have a number of relatively minor suggestions to
improve the clarity and readability of the paper before publication.
Abstract:
1. In the Methods, make it clear that the daily ratings of depressive symptoms include a summary
score and individual symptoms (perhaps list them if the word count will allow). As you have
highlighted the need for a symptom-specific approach in the Conclusion it is important this is
clear in the Abstract alone.
Introduction:
1. You have discussed the possible role of hormone fluctuations/sensitivity in the cyclical nature
of depressive symptoms and, whilst this is a supported plausible mechanism, it is still somewhat
debated. It would improve the Introduction to slightly reword to imply this mechanism is still
under investigation (for example: “hormone fluctuations have been associated with physical
and psychological states” and “ovarian hormone fluctuations across the menstrual cycle could
plausibly result in cyclical change of depressive symptoms”). Also, other mechanisms (notably
inflammation) have been shown to vary across the menstrual cycle and may play a role -
it would be great to see this also mentioned. Here is a possibly useful citation: Tiranini L,
Nappi RE. Recent advances in understanding/management of premenstrual dysphoric disorder/
premenstrual syndrome. Fac Rev. 2022 Apr 28;11:11. doi: 10.12703/r/11-11. PMID: 35574174;
PMCID: PMC9066446.
2. I would suggest rewording “single depressive symptoms” to “individual depressive
symptoms” as some readers may initially interpret single depressive symptom as referring to
one overall summary score.
Method:
1. In the Participants section, please specify the university and country/location of the study.
2. Please add information on the menstrual bleeding and menstruation pain assessments – what
were the questions, was it reported on a scale, etc. (can be in the appendix).
3. It was somewhat unclear where the SCID-5-CV was used. Was this just used in the screening
procedure? If so, it may be clearer to move the description of the measure (2.3.1) into the
screening section (2.2.1). Otherwise, please clarify in section 2.3.1 when this was used.
4. In Section 2.3.2 you repeat yourself first saying “Instead of assessing symptom severity
retrospectively for the last two weeks, we asked participants to rate the current moment (How
much do you feel affected by the following symptoms right now?).” and then saying “The
answering format was changed from rating symptom frequency across the last two weeks to
rating the intensity in the current moment on a 6-point Likert scale from 0 - not at all to 5 - very
strongly.” Please reword this to be more concise and only state once that you are asking about
symptoms at the current moment instead of for the last two weeks.
5. In Section 2.4.3, you say “To address this, adapted…” – I believe you wish to say “we
adapted”.
Results:
1. At the end of Section 3.2, you say that “Because Item 3 was only assessed in the morning, it
was discarded from the following analyses”. This information would be more beneficial in the
Methods – please move it up.
2. The description of the comparison of cyclicity between depressed and non-depressed groups
(bottom of page 15) does not seem to be accompanied by a Table or Figure detailing all of these
analysis results. You seem to only mention the ‘significant’ results in the text. Please include a
table showing the results for every symptom comparison, regardless of ‘significance’.
Discussion:
1. Similar to the comment I have made for the Introduction, you may need to reword some
of your discussion regarding hormone sensitivity. You say “our results confirm the presence
of individual differences in hormone sensitivity for depressive symptoms”; however, I do not
believe this to be true. Your results confirm individual differences in depressive symptoms over
the menstrual cycle and one possible explanation for this could be hormone sensitivity. Please
reword this to ensure you are not over-interpreting your findings.
Figures/Tables:
1. Figure 1 could be improved to better illustrate the various points you have made in the text.
Firstly, please make it clear that each row in this Figure is a participant (this is in the Footnote but
is not very obvious and would be better if this was included on the Y axis somehow). Secondly,
whilst the cc trajectories are clear for each time, this Figure doesn’t clearly show the values for
internal consistency across these times. You state in the text (2.4.2) how high and low internal
consistency values would be interpreted but Figure 1 doesn’t clearly demonstrate this; instead,
it is the last point made in the Footnote. Please make this clearer in the Figure (especially as
this is its first mention in the text and so readers may look to this Figure for that information
first and struggle to find it).
2. Overall, Tables 2 and 3, and Figure 2, are challenging to interpret without reading
the manuscript in detail. Please add more information/explanation to the Tables (headings,
footnotes) so they can be understood in isolation. It would also aid the reader if you included
the Item numbers in these Tables (as you have done in Figure 2) to enable easier comparison
with the manuscript text.
General:
1. The use of ‘significant’ is often frowned upon as it relies on some arbitrary threshold and,
whilst you’ve said you have based this on the confidence intervals (as opposed to the traditional p
value), this is just using another value to select the threshold. It would be better if you commented
on the strength of evidence and meaningfulness of effect estimates instead. Also, it is not always
clear if use of the word significant refers to clinical significance, statistical significance, or other
– I would therefore suggest rephrasing to avoid any confusion.
2. Some of your abbreviations are defined in text (e.g., PMDD) whilst others are only defined in
the abbreviations list (e.g., LH). Please be consistent in how abbreviations are defined - I would
suggest defining in text at their first mention to aid readability if possible.
3. Your citation style changes as you start using number in the Introduction and later in the
Methods use first author and date. Please be consistent with referencing/citation style.