PONE-D-22-06008

The cross-sectional association of stressful life events with depression severity among patients with hypertension and diabetes in Malawi

PLOS ONE

Dear Dr. Landrum,

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The reviewers have raised a number of concerns. They request improvements to the reporting of methodological aspects of the study (such as how the DAGs were constructed, and the description of the depression covariate), and revisions to the discussion.

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“This study received funding from the National Institute of Mental Health (MPIs: Brian W. Pence, PhD, Mina C. Hosseinipour, MD MPH; Jones Masiye; U19MH113202-01). KRL received support from supplement U19MH113202-04S1. JD received support from supplement U19MH113202-01S2 and T32AI070114.  Neither the funding agency nor funders had any part in study conceptualization, data collection, data analysis, or decision-making about publication.”

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“This study received funding from the National Institute of Mental Health (MPIs: Brian W. Pence, PhD, Mina C. Hosseinipour, MD MPH; Jones Masiye; U19MH113202-01). KRL received support from supplement U19MH113202-04S1. JD received support from supplement U19MH113202-01S2 and T32AI070114.  Neither the funding agency nor funders had any part in study conceptualization, data collection, data analysis, or decision-making about publication.”

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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: Partly

Reviewer #2: Yes

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

Reviewer #1: I Don't Know

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?

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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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: It is an interesting and welcome paper on adults with NCDs. This population should require more attention in LMICs, especially when they also suffer from depressive symptoms. The paper is well structured and references are numerous.

Though I have some questions and comments:

I would not say that depression remains “disproportionately “ high in LMICs seeing the high diversity in prevalence rates that are given in the following rates. These rates should be a bit more contextualized as you may have different screening tools with various identified period (from the last 2 weeks to in the lifecourse) and different sampled population.

Qualifying SLEs as "promising" risk factors seems to me a bit clumsy. It also rises the question of the objective of the paper. Do the authors want to promote SLEs as a predictors of depression? are they really easier to identify than depression in a data collection? Looking at the SF1 & 2, it does not look like but perhaps it is because of the sensitivity of the questions related to depression? in this case, it has to be clearly mentioned.

I am also wondering how the interaction Depression*SLE*NCD is treated in the paper. To me, it looks like this study could be conducted on general population which is not. I am curious to know how many people with NCDs do not show any depressive symptoms for instance to understand how large is the combination NCD*depression. That would support the choice that has been done here to conduct the study only on people who show some depressive signs. Otherwise, this selection is questioning and should be discussed. Indeed, we could also think that many people, on the contrary do not develop depressive symptoms while they have experiences SLEs.

The data collection occurred during the covid pandemic: Has the covid-pandemic a dramatic impact in Malawi? Not sure it has, however, it may have impacted life conditions at least for a certain period of time. It could also change the way people were interviewed with the need to respect some physical distance. It could be helpful to develop a bit more for the readers who do not know the context.

I believe the analysis is well done and statistically appropriate but I am questioning about the relevance to estimate a constant cumulative risk when having experienced an additional SLE with some that have been shown to impact more than others.

I was also surprised not to see in the discussion about the timeline of the SLEs. Indeed, except for injuries (that are in fact insignificant), many events result from processes: being diagnosed from a new disease result from having symptoms enough worrying to consult, getting married or divorced result from previous preliminary events and depression could become worsen on the long run.

It is also true for physical assault that may be a repetitive event for some participants. It is quite high for this population and it would have been welcome to test some specific gender-oriented associations between SLE and depression. Again, I was wondering what would have been the prevalence of depression in a population who experience so high insecurity feelings and if people with NCDs are specific from this respect.

Finally, to come back to one of my first remark, there is a need to more connect these results to the fact that the participants live with NCDs. I have two suggestions to do so: first is to test the association between depression severity and the specific NCD the participants suffer from and including it in the models. The second is to explore the association between NCDs and the SLE: it is probably not independent to be sick and lose a job or a spouse. At least, all these issues should be discussed.

Punctual remarks

The description of the depression covariate should clearly mention that the screening collect symptoms for the last 2 weeks at the baseline.

The DAG presented in SF3 should be included in the paper.

The frequencies of the people excluded because of missing data and of disagreement in the screening should be reported in parenthesis.

thresholds are for some of them a bit surprising in tables.

the authors should make a distinction between having no experience and having at least 1 or 2 as the firsts are supposed to be very different from the others, and group the last 2 groups (9+) that are really a minority.

going to bed hungry: group the last 3 groups that are really a minority.

there is no need to qualify the parity, just mention the number of children.

Reviewer #2: The authors conduct a cross-sectional study to estimate the association between SLEs and depressive severity among 708 patients who seek for NCD care. The results showed that SLEs in the prior 3 months were associated with greater depressive severity.

1. Confounders adjusted in the final model were identified through the DAGs. Please explain how the DAGs were constructed.

2. Participants were recruited across 10 study sites. Are the participants from different sites homogeneous?

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Reviewer #1: Yes: Géraldine Duthé

Reviewer #2: No

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The cross-sectional association of stressful life events with depression severity among patients with hypertension and diabetes in Malawi

PONE-D-22-06008R1

Dear Dr. Landrum,

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.

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Yann Benetreau

Staff Editor

PLOS ONE

Additional Editor Comments (optional):

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: (No Response)

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

Reviewer #1: Yes

Reviewer #2: (No Response)

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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: (No Response)

Reviewer #2: (No Response)

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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: (No Response)

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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: (No Response)

Reviewer #2: (No Response)

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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: Yes: Géraldine Duthé

Reviewer #2: No

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