Multimodal Biomarkers and Precision TMS for Postpartum Depression

Postpartum depressive symptom severity measured by the Edinburgh Postnatal Depression Scale (EPDS)

The EPDS total score ranges from 0 to 30, with higher scores indicating greater postpartum depressive symptom severity. Scores of 10 or above indicate elevated depressive symptoms, while scores of 13 or above are commonly used as a threshold for probable postpartum depression. The EPDS will serve as the primary measure of postpartum depressive symptom severity and risk identification. EPDS scores will be tracked longitudinally from late pregnancy through 3 months postpartum to characterize symptom development and identify high-risk individuals.

Self-reported depressive symptom severity measured by the Beck Depression Inventory-II (BDI-II)

The BDI-II will be used to assess self-reported depressive symptom severity. The BDI-II total score ranges from 0 to 63, with higher scores indicating more severe depressive symptoms. Scores of 0-13 indicate minimal depression, 14-19 mild depression, 20-28 moderate depression, and 29-63 severe depression.

Depression severity measured by the 17-item Hamilton Depression Rating Scale (HAMD-17)

The HAMD-17 total score ranges from 0 to 52, with higher scores indicating greater depression severity. Scores of 0-7 are generally considered normal, 8-16 mild depression, 17-23 moderate depression, and ≥24 severe depression.

Quality of life measured by the WHO Quality of Life Instrument-Short Form (WHOQOL-BREF)

The WHOQOL-BREF is a 26-item self-report questionnaire used to assess quality of life across four distinct domains: Physical Health (7 items), Psychological Health (6 items), Social Relationships (3 items), and Environment (8 items). Each item is rated on a 5-point Likert scale. Raw domain scores are mathematically transformed to a linear 0 to 100 scale for each domain according to the official WHO guidelines. Scores range from 0 to 100, where higher scores represent a better perceived quality of life in that specific domain.

Area Under the Receiver Operating Characteristic Curve for Prediction of rTMS Treatment Response

The area under the receiver operating characteristic curve (AUC) will be used to evaluate the ability of the multimodal machine-learning model to discriminate between participants with and without a prespecified clinical response to repetitive transcranial magnetic stimulation (rTMS). AUC values range from 0.5 to 1.0, with higher values indicating better discrimination.

F1-Score of the Multimodal Model for Prediction of rTMS Treatment Response

The F1-score will be used to evaluate the balance between precision and sensitivity of the multimodal machine-learning model in classifying participants with and without a prespecified clinical response to repetitive transcranial magnetic stimulation (rTMS). The F1-score ranges from 0 to 1, with higher values indicating better classification performance.

Clinical Response to Robot-Guided rTMS Treatment

Clinical response to robot-guided repetitive Transcranial Magnetic Stimulation (rTMS) will be evaluated by changes in depression symptom severity measured using clinician-rated and self-reported depression scales before and after treatment. Treatment response will be defined based on percentage reduction in depressive symptoms and categorical responder status where applicable.

Association Between Baseline Multimodal Biomarkers and rTMS Treatment Response

Baseline multimodal biomarkers, including EEG features, autonomic indices, peripheral inflammatory and endocrine markers, and interoceptive measures, will be examined as potential predictors of individual variability in clinical response following rTMS treatment.

Fertility Intentions

A structured self-report questionnaire will be used to assess subjective fertility intention and future fertility aspirations. Lower scores or negative responses reflect a reduced intention or aspiration for future fertility. This exploratory measure will be correlated with perinatal depressive symptoms, interoceptive awareness, and quality of life scores to explore how physiological and psychological stress during the transition to motherhood influences future fertility decisions.

Subjective Experiences and Perceptions of the Traditional Postpartum Ritual ("Sitting-the-Month")

Participants' subjective experiences, cultural compliance, and perceived psychological stress related to the traditional Chinese postpartum confinement ritual ("sitting-the-month") will be evaluated using a structured self-report questionnaire. Scores will capture dimensions of perceived emotional support versus behavioral restriction and interpersonal friction within the family.