Depression, anxiety, burnout and empathy among Spanish medical students

Patricia Capdevila-Gaudens; J. Miguel García-Abajo; Diego Flores-Funes; Mila García-Barbero; Joaquín García-Estañ

doi:10.1371/journal.pone.0260359

Peer Review History

Original SubmissionApril 11, 2021
11 Apr 2021 Author Response Attachments Attachment Submitted filename: Rebuttal letter.docx https://doi.org/10.1371/journal.pone.0260359.r001
5 Aug 2021 Decision Letter - Kamran Sattar, Editor PONE-D-21-11578 Depression, Anxiety, Burnout and Empathy among Spanish Medical Students PLOS ONE Dear Dr. Garcia-Estañ, 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 19 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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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The manuscript offers an overview on medical students mental health in Spain. The strength of the study was the national scale study. However, I feel that the manuscript need to be improved based on the following comments before it is ready for publication. This manuscript would need a native speaker proofreading to increase the readability of the findings. There is a glaring grammatical and spelling (eg: PubMed) errors throughout the manuscript. Abstract: Need to include study objective and some general methodology before jumping to results. Worthwhile to include the tools in the abstract so that readers can grasp whether the depression/anxiety prevalence was more of positive symptoms or diagnosis. Introduction: 1. The introduction focused only on depression while the constructs measured also include burnout, anxiety and empathy. Hence, authors could incorporate this flow in the introduction Introduction on burnout, depression and anxiety and some overview in general population - High prevalence of burnout, depression and anxiety - why it is more pronounced among medical students - the impact of these mental health problems if not addressed (including empathy) - why empathy is important in medical training - lack of studies looking into this in Spanish context 2. A search in Pubmed (October 6, 2020) revealed 859 articles featuring the Spanish word for "depression" and 517 featuring the Spanish term for “medical students". The union of the two terms returned no records at all. (From my search, it seems there is such study (PMID: 32920780). Hence, this paragraph should be updated. 3. Some introduction on medical training and the structure in Spain is necessary since this is a national scale study. It would help readers to understand which are pre and clinical year students. Methods: 1. First para: Need to include population size or estimate to give some picture to readers. 2. Each instruments need to be introduced separately in individual paragraph for a better flow- purpose of the instrument (screening or diagnosis), whether it was administered in English or Spanish version, validation in Spanish or medical students context, with reliability mentioned - scores calculation (whether there is dichotomous classification or measured as continuous variable). Note that validation must be mentioned specifically for the instruments (eg. CBI) rather than the construct (eg. Burnout) 3. Some explanation is needed to help readers in the difference of anxiety state vs trait 4. What is p75? 5. Statistical analysis - more details are needed what are the independent variables included for each logistic regression analyses? How was the independent variables selected for the multivariable model? (Some study used cutoff of p-value more than 0.2 for each univariate analysis run) Results 1. "Cronbach's alpha coefficients were 0.923 (Beck's test), 0.703 (Maslach), 0.809 (Jefferson), 0.378 (state anxiety) and 0.365 (trait anxiety)." - I think this is not necessary as validation should be done in a separate cohort rather than the actual sample. 2. Table 1 - Percentage (%) should be in form of 22.9 rather than 22,9. 3. Table 1 - Age should be excluded and just mentioned in the paragraph in form of mean and standard deviation. 4. Second para: Authors refer this para as Table 1 but it seems there were 6 subgroup analyses that were not in Table 1. These subgroup analyses were mentioned selectively rather than comprehensively. Hence, authors should rethink whether this subgroup analysis need a separate table. 5. I suggest that Figure 1 to Figure 5 is changed into Table. It is difficult to read the result precisely from the bar chart. 6. "Percentage of depression was also significantly higher among 2nd, 3rd, and 4th year students, with those in their 1st and 6th years scoring lowest in this sense (Figure 2)" - How did authors came to this statement. Was one-way ANOVA conducted to ascertain this? - This comment also applies to paragraph on anxiety, burnout and empathy. 7. There was untranslated Spanish words in Table 3. 8. Drugs and substance abuse: "... with this percentage again being significantly higher among men.." - Authors must be careful when saying significantly unless there was t test or anova done to ascertain the association. 9. Multivariate relationships between DABE variables and risk predictors - Multivariable instead of multivariate 10. Table 4-7 (Inferior superior should be named as lower and upper) 11. p value of 0.000 should be written as p-value < 0.001 Discussion 1. "We therefore believe that the results offer an accurate and highly relevant overview of the mental health of medical students in our country" - I think this is overinflation of the study, plus it is a non-probability sampling. A better way to say this is - the number of participants may reflect the true situation of the problem in Spain medical training. 2. Second para is misleading as BDI is a screening tool rather than diagnostic. Hence the overall prevalence is more of depression symptoms rather than depression. 3. Second para - last 2 sentences were repetitive of result section. This should be discussed, compared or contrast rather than being repeated. 4. "... suggesting that the prevalence of burnout among medical students is fairly similar to that found among medical residents and practicing physicians (27)." reference given was studies on medical students. Hence a proper citation is needed. 5. Last para: The second last sentence was also repeating the result. Some critical discussion is desirable. Why anxiety trait and state could be highly correlated? What could this mean to educators or medical training. 6. Last sentence: Maybe this can help authors to expand the discussion https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6696211/ Strengths and limitations. 1. Need to emphasis the instruments are screening rather than diagnostic. 2. Other limitations have to be discussed - non probability sampling 2. Only captured more of individual constructs. Institutional constructs that may contribute to DABE were not captured Conclusion only emphasized on high prevalence of DAB. No mention of empathy which was part of the study objective. ****** 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 [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. 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Revision 1
21 Oct 2021 Author Response Answers marked in red in the Response To Reviewers document. Reviewer #1: The manuscript offers an overview on medical students mental health in Spain. The strength of the study was the national scale study. However, I feel that the manuscript need to be improved based on the following comments before it is ready for publication. This manuscript would need a native speaker proofreading to increase the readability of the findings. There is a glaring grammatical and spelling (eg: PubMed) errors throughout the manuscript. We are sorry, the manuscript was revised by a native professional but probably the last additions to the manuscript included some errors. Ms. Diana Draper has revised it again. Abstract: Need to include study objective and some general methodology before jumping to results. Worthwhile to include the tools in the abstract so that readers can grasp whether the depression/anxiety prevalence was more of positive symptoms or diagnosis. We agree with the reviewer, and we have included two paragraphs dealing with the objective and the methods employed. Introduction: 1. The introduction focused only on depression while the constructs measured also include burnout, anxiety and empathy. Hence, authors could incorporate this flow in the introduction. Again, we agree. We have included a new paragraph in the introduction. Introduction on burnout, depression and anxiety and some overview in general population - High prevalence of burnout, depression and anxiety - why it is more pronounced among medical students - the impact of these mental health problems if not addressed (including empathy) - why empathy is important in medical training - lack of studies looking into this in Spanish context 2. A search in Pubmed (October 6, 2020) revealed 859 articles featuring the Spanish word for "depression" and 517 featuring the Spanish term for “medical students". The union of the two terms returned no records at all. (From my search, it seems there is such study (PMID: 32920780). Hence, this paragraph should be updated. Yes, the reviewer is right, the article was referenced in our list, but it did not appear in our search then. This spanish journal probably was not indexed immediately. 3. Some introduction on medical training and the structure in Spain is necessary since this is a national scale study. It would help readers to understand which are pre and clinical year students. Ok, we agree and a paragraph has been included in the introduction. Methods: 1. First para: Need to include population size or estimate to give some picture to readers. Ok, the population number was included originally in the first paragraph of Discussion. This has been also included now in the first paragraph of Methods. 2. Each instruments need to be introduced separately in individual paragraph for a better flow- purpose of the instrument (screening or diagnosis), whether it was administered in English or Spanish version, validation in Spanish or medical students context, with reliability mentioned - scores calculation (whether there is dichotomous classification or measured as continuous variable). Note that validation must be mentioned specifically for the instruments (eg. CBI) rather than the construct (eg. Burnout) We agree, all the instruments ar enow in separate paragraphs. 3. Some explanation is needed to help readers in the difference of anxiety state vs trait. Ok, a new paragraph has been inserted in Methods. 4. What is p75? It is the 75th percentile or third quartile (Q3). This has been included in the revised manuscript. 5. Statistical analysis - more details are needed what are the independent variables included for each logistic regression analyses? How was the independent variables selected for the multivariable model? (Some study used cutoff of p-value more than 0.2 for each univariate analysis run). All the variables (except depression, burnout, anxiety and empathy that were the dependent variables) were the independent variables and we only selected those that gave a significant p value (less than 0.05) in the previous bivariate tests. This has been also added to the paragraph. Results 1. "Cronbach's alpha coefficients were 0.923 (Beck's test), 0.703 (Maslach), 0.809 (Jefferson), 0.378 (state anxiety) and 0.365 (trait anxiety)." - I think this is not necessary as validation should be done in a separate cohort rather than the actual sample. Yes, we removed this paragraph. 2. Table 1 - Percentage (%) should be in form of 22.9 rather than 22,9. We are sorry, we have corrected it. 3. Table 1 - Age should be excluded and just mentioned in the paragraph in form of mean and standard deviation. Yes, we have included these numbers. 4. Second para: Authors refer this para as Table 1 but it seems there were 6 subgroup analyses that were not in Table 1. These subgroup analyses were mentioned selectively rather than comprehensively. Hence, authors should rethink whether this subgroup analysis need a separate table. The reviewer is right. We added these”subgroups” comments in order to give some more information. Since there are so many tables, we have decided to add the sentence ”data not shown”. We hope you agree, but if necessary we will add these new tables. 5. I suggest that Figure 1 to Figure 5 is changed into Table. It is difficult to read the result precisely from the bar chart. We agree with the reviewer and all these figures have been changed to a table, new table 2. 6. "Percentage of depression was also significantly higher among 2nd, 3rd, and 4th year students, with those in their 1st and 6th years scoring lowest in this sense (Figure 2)" - How did authors came to this statement. Was one-way ANOVA conducted to ascertain this? - This comment also applies to paragraph on anxiety, burnout and empathy. The term significantly was used only when the chi square p level was lower than 0.05. Then, the rest of sentences just tell the values that are lower and greater, but ANOVA was not performed to obtain significance among them. We have corrected all these sentences to indicate only when there are significant differences. 7. There was untranslated Spanish words in Table 3. We are sorry, we have corrected it. 8. Drugs and substance abuse: "... with this percentage again being significantly higher among men.." - Authors must be careful when saying significantly unless there was t test or anova done to ascertain the association. Yes, answered in point 6 above. 9. Multivariate relationships between DABE variables and risk predictors - Multivariable instead of multivariate. Ok, we have corrected it. 10. Table 4-7 (Inferior superior should be named as lower and upper). Ok, we have corrected it. 11. p value of 0.000 should be written as p-value < 0.001. Ok, we have corrected it. Discussion 1. "We therefore believe that the results offer an accurate and highly relevant overview of the mental health of medical students in our country" - I think this is overinflation of the study, plus it is a non-probability sampling. A better way to say this is - the number of participants may reflect the true situation of the problem in Spain medical training. Yes, the reviewer is right. We have changed it in the last lines of the first para of Discussion. 2. Second para is misleading as BDI is a screening tool rather than diagnostic. Hence the overall prevalence is more of depression symptoms rather than depression. Yes, the reviewer is right. We have included the term symptoms in several places in the paragraph. 3. Second para - last 2 sentences were repetitive of result section. This should be discussed, compared or contrast rather than being repeated. The reviewer is right and we have eliminated it. 4. "... suggesting that the prevalence of burnout among medical students is fairly similar to that found among medical residents and practicing physicians (27)." reference given was studies on medical students. Hence a proper citation is needed. Our error, reference should be number 26. 5. Last para: The second last sentence was also repeating the result. Some critical discussion is desirable. Why anxiety trait and state could be highly correlated? What could this mean to educators or medical training. Regarding the correlation between both anxiety state and trait, it is question that still remains unanswered. According to an early formulation, anxiety is a unidimensional construct including both state and trait anxiety, considered to be different sides of the same coin. However, other authors suggested trait and state anxiety to be separate multidimensional constructs. 6. Last sentence: Maybe this can help authors to expand the discussion https://www.ncbi.nlm.nih.gov/ Thank you very much, it is a quite good paper. We have referenced it (new ref. 40) and added a sentence to the last paragraph. Strengths and limitations. 1. Need to emphasis the instruments are screening rather than diagnostic. Yes, we have added it. 2. Other limitations have to be discussed - non probability sampling. Yes, we also added it. 2. Only captured more of individual constructs. Institutional constructs that may contribute to DABE were not captured. The reviewer is right, we have included a paragraph about it. Conclusion only emphasized on high prevalence of DAB. No mention of empathy which was part of the study objective. The reviewer is right, we have included a paragraph on empathy. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0260359.r003
9 Nov 2021 Decision Letter - Kamran Sattar, Editor Depression, Anxiety, Burnout and Empathy among Spanish Medical Students PONE-D-21-11578R1 Dear Dr. Garcia-Estañ, 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, Kamran Sattar Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0260359.r004
Formally Accepted
17 Nov 2021 Acceptance Letter - Kamran Sattar, Editor PONE-D-21-11578R1 Depression, Anxiety, Burnout and Empathy among Spanish Medical Students Dear Dr. García-Estañ: 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. Kamran Sattar Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0260359.r005

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