Psychosis risk among pregnant women in Ghana

Samuel Adjorlolo; Gwendolyn Mensah; Caroline Dinam Badzi

doi:10.1371/journal.pone.0263011

Peer Review History

Original SubmissionJune 19, 2021
16 Aug 2021 Decision Letter - Frank T. Spradley, Editor PONE-D-21-20182 Psychosis Risk among Pregnant Women in Ghana PLOS ONE Dear Dr. Adjorlolo, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Sep 30 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide." 3. Please include a copy of Table xxxx which you refer to in your text on page 11. Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. 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 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 [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. Attachments Attachment Submitted filename: The study presents the results of original research.docx https://doi.org/10.1371/journal.pone.0263011.r001
Revision 1
22 Oct 2021 Author Response 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. Attachments Attachment Submitted filename: Response to Reviewer comments.docx* https://doi.org/10.1371/journal.pone.0263011.r002
16 Nov 2021 Decision Letter - Frank T. Spradley, Editor PONE-D-21-20182R1Psychosis Risk among Pregnant Women in GhanaPLOS ONE Dear Dr. Adjorlolo, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Dec 31 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: 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'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. 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 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. https://doi.org/10.1371/journal.pone.0263011.r003
Revision 2
20 Nov 2021 Author Response 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. Attachments Attachment Submitted filename: Response to reviewer comments 2.docx https://doi.org/10.1371/journal.pone.0263011.r004
3 Dec 2021 Decision Letter - Frank T. Spradley, Editor PONE-D-21-20182R2Psychosis Risk among Pregnant Women in GhanaPLOS ONE Dear Dr. Adjorlolo, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jan 17 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: 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'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. 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 Journal Requirements: 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 ****** 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. https://doi.org/10.1371/journal.pone.0263011.r005
Revision 3
8 Dec 2021 Author Response 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. Authors’ response: Thank you very much for the feedback. It is our understanding that the scales of measurement have been presented in a manner that the research community can follow. We would be happy if this is accepted the way it is. • 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 Authors response: We are grateful for the comments. In the earlier version of the manuscript, we accepted your recommendation and included a conclusion statement. In this revised version, we have expanded on this conclusion section as follows; “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.” Attachments Attachment Submitted filename: Reviewer comments.docx https://doi.org/10.1371/journal.pone.0263011.r006
11 Jan 2022 Decision Letter - Frank T. Spradley, Editor Psychosis Risk among Pregnant Women in Ghana PONE-D-21-20182R3 Dear Dr. Adjorlolo, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Frank T. Spradley Academic Editor 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 Authors Thank you very much for responding to my recommendations immediately. I wish you a good luck! ****** 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 https://doi.org/10.1371/journal.pone.0263011.r007
Formally Accepted
25 Jan 2022 Acceptance Letter - Frank T. Spradley, Editor PONE-D-21-20182R3 Psychosis Risk among Pregnant Women in Ghana Dear Dr. Adjorlolo: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. PLOS Manuscript Reassignment Staff Editor PLOS ONE https://doi.org/10.1371/journal.pone.0263011.r008

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