PONE-D-20-08024

Prevalence and associated factors of suicidal ideation and attempt among undergraduate medical students of Haramaya University, Ethiopia. A cross sectional study

PLOS ONE

Dear Mr Asfaw,

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Marco Innamorati

Academic Editor

PLOS ONE

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https://doi.org/10.1016/j.jflm.2014.08.006

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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

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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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: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

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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: This is, in summary, an interesting paper aimed to assess the prevalence and associated factors of suicidal ideations and attempts among undergraduate medical students of Haramaya University in a sample of 757 subjects. The study showed that the prevalence of suicidal ideation and attempts were 23.7% and 3.9%, respectively. Cumulative Grade Point Average, current alcohol use, depression, anxiety, and poor social support were significantly associated with suicidal ideation. In addition, depression and anxiety were linked to suicidal attempts.

The authors may find as follows my main comments/suggestions.

First, when within the Introduction section, the authors correctly reported that suicial behavior is a major health priority being the second leading cause of death among adolescents and young adults, they might even briefly refer to the possible link between suicidal behavior, biological abnormalities, and emotional turmoil related to bereavement. Specifically, the emotional turmoil in suicide survivors of patients died by suicide may last a long time, and in some cases, may end with their own suicide. Thus, it is fundamental to understand the bereavement process after the suicide of a significant other in order to provide a proper care, and improve the outcomes. In order to briefly discuss this topic (although i understand that the link between suicidal behavior, and emotional turmoil related to bereavement process is not the main topic of the present manuscript), i suggest to discuss and cite, within the main text, the following papers (PMID: 31647957, 24082246, 30601750). In addition, specific biological abnormalities (e.g., prolactin, thyroid hormones, and immune alterations) may be significantly associated with suicidal behavior even involved in a complex compensatory mechanism to correct the abnormal central serotonin activity. The assumption that specific biological abnormalities may be associated or even predict suicidal behavior is of great importance, given the availability of such data in everyday clinical practice. Physicians of any kind as well as mental health professionals should be aware of the importance to insert as much information possible in the assessment of suicide. Thus, given the above information, my additional suggestion is also to briefly discuss and include throughout the manuscript the following additional reports (PMID: 30601750, 22748186, 29926090).

Moreover, as the main aims/objectives of this paper have been well described, the most relevant hypotheses underlying the present study should be reported as well in a detailed manner.

Furthermore, the section results is, in my opinion, divided in too many subsections that are difficult to follow for the general readership. Here, the most relevant study findings need to be better summarized for clarity.

In addition, the section limitations/shortcomings needs to be more directly updated as the most relevant caveats have been only partially described.

Also, the manuscript needs to be reviewed by a native English speaker for the quality of language.

Finally, what is the take-home message of this study? While the authors reported that the university should give due emphasis to reduce the risk factors and provide psychosocial support, they failed to report the most relevant conclusive remarks of their paper. Here, more details/information are required.

Reviewer #2: This is an interesting study with a potential clinical relevance focusing on suicidal behaviour in undergraduate medical students. The paper present an important topic, with a concise introduction, adequate and well described methodology, well presented results and conclusions that are supported by the findings. A few comments to improve the paper:

1. The language of the paper should be tuned to be a bit more "scientific" please work on this. Also correct several typing mistakes, starting with capitalisation of affiliation, missing or unnecessary spaces, etc.

2. Abstract: the same applies. I believe also that if you provide a definition of suicide as PLOS has a general audience please keep it less "naive". Also provide more sound rationale in the abstract for this study. Also: conclusion of abstract should express more than prevalence was "high". compared to what?

3. Methods: there was a one-month data collection period. Suicidal behaviour is linked to several stress- and environment related factors. Why I am not familiar with possible year-round fluctuations of Ethiopian weather, which is present in more northern home countries, the lack of such influencing factors should also be mentioned. Furthermore, i wonder how this period related to other possible risk stress factors like onset exam period. Therefore please comment on the choice of this period for data collection and the possible associated factors which may have to be considered when interpreting the data.

4. Was the sample representative with respect to factors other than year of medical university? such as socioeconomic background, family background, age, religion, etc?

5. How was suicidal ideation specifically assessed, by what question?

6. Was there correction for possible confounding variables?

7. Were students with psychiatric disorders excluded? Was there screening for depression or anxiety and correction for these variables? Is there data on medications taken that could influence depression and suicidality in any direction?

8. Is there data available in suicidal behaviour prevalence in Ethiopia? It would be necessary to compare the prevalence found in this study to genera population data.

In general although I have a few problems with the present study, the findings are interesting and the discussion is, while fully supported by the data, complex and thorough. After major revision the paper is worthy of publication.

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Reviewer #1: No

Reviewer #2: No

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Prevalence and associated factors of suicidal ideation and attempt among undergraduate medical students of Haramaya University, Ethiopia. A cross sectional study

PONE-D-20-08024R1

Dear Dr. Asfaw,

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.

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Kind regards,

Marco Innamorati

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

Reviewer #2: All comments have been addressed

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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

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: 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

Reviewer #2: Yes

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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

Reviewer #2: Yes

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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: In the revised manuscript, the authors addressed successfully most of the major questions raised by Reviewers improving both the main structure and quality of the present paper. I have no further additional comments.

Reviewer #2: The authors ahve addressed all comments raised by the reviewer whch improved this already good paper. Therefore I recommend to publish the paper in its present form. I also congratulate the authors, especially give that they arejunior scientists.

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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

Reviewer #2: No