PONE-D-22-19049

Trends in Suicide Rates by Race/Ethnicity among Members of the United States Army

PLOS ONE

Dear Dr. Brenner:

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.

==============================

We have conducted the initial review of criteria for publication, and discovered the following sections that require attention: Financial Disclosure, Ethics Statement and Data Availability. Specifically, these three sections require expansion and where indicated, specific explanations.

The left margin of the manuscript draft provides an overview of information and templates/examples of what is required; additional information may be found at the following links.

https://journals.plos.org/plosone/s/criteria-for-publication

https://journals.plos.org/plosone/s/submission-guidelines#loc-guidelines-for-specific-study-types https://journals.plos.org/plosone/s/criteria-for-publication#loc-7

https://journals.plos.org/plosone/s/data-availability We look forward to the revision of these sections so we may continue processing the manuscript.

==============================

Please submit your revised manuscript by August 9, 2022.  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.

We look forward to receiving your revised manuscript.

Kind regards,

Darrell Eugene Singer, M.D., M.P.H.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. 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 

" ext-link-type="uri" xlink:type="simple">https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf"

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information.

3. Thank you for stating the following in the Acknowledgments Section of your manuscript: 

"This study was funded by the National Institute of Mental Health and Office

of the Director at NIH (R01MH120122). Funding to support cohort development was from the

National Center for Complementary and Integrative Health (NCCIH; R01 AT008404) and the

National Institute on Drug Abuse (NIDA; R01 DA030150). Our Department of Defense data

sponsor is Major Ryan C. Costantino, PharmD - formerly it was Dr. Chester Buckenmaier, III

until recent retirement."

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. 

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: 

"This study was funded by the National Institute of Mental Health (NIH) and Office of the Director at NIH (R01MH120122). Funding to support cohort development was from the National Center for Complementary and Integrative Health (NCCIH; R01 AT008404) and the National Institute on Drug Abuse (NIDA; R01 DA030150). Our Department of Defense data sponsor is Major Ryan C. Costantino, PharmD - formerly it was Dr. Chester Buckenmaier, III until recent retirement.

All authors received funding.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

https://www.nimh.nih.gov/

https://www.nih.gov/

" ext-link-type="uri" xlink:type="simple">https://www.nccih.nih.gov/"

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

5. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical.

6. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

7. 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.

Additional Editor Comments:

Dear Dr. Brenner:

My apologies for the delay in responding to your message- (I was experiencing a few technical issues on this end). I am resending the message I'd previously sent with this Minor Revision request- specifically, to address the PLOS ONE's data availability, ethics statement and financial disclosure requirements and details within the disclosures. PLOS won't publish without a deeper explanation of your data concerns.

I have have two reviewers prepared to formally review your manuscript; I have also reviewed it myself and do not anticipate any major problems or concerns (outside of the previously mentioned concerns-).

We look forward to continuing to process the manuscript subsequent to resubmission.

Regards, Darrell Singer

Dr. Brenner:

Thank you for your interest in PLOS ONE and submission of your manuscript "Trends in Suicide Rates by Race and Ethnicity among Members of the United States Army".

We are conducting the initial review of criteria for publication, and discovered the following sections that require attention: Financial Disclosure, Ethics Statement and Data Availability.

Specifically, these three sections require expansion and where indicated, specific explanations. The left margin of the manuscript draft provides an overview of information and templates/examples of what is required; additional information may be found at the following links.

https://journals.plos.org/plosone/s/criteria-for-publication

https://journals.plos.org/plosone/s/submission-guidelines#loc-guidelines-for-specific-study-types

https://journals.plos.org/plosone/s/criteria-for-publication#loc-7

https://journals.plos.org/plosone/s/data-availability

We look forward to the revision of these sections so we may continue processing the manuscript.

Regards,

Darrell Eugene Singer, M.D., M.P.H.

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

[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.

PONE-D-22-19049R1

Trends in Suicide Rates by Race and Ethnicity among Members of the United States Army

PLOS ONE

Dear Dr. Brenner,

Thank you for re-submitting your manuscript to PLOS ONE.  Your manuscript presents important information on military post-deployment suicides and in particular, demonstrating changes over time periods may provide insight into risks to specific groups of service members. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands.  We  invite you to submit a revised version of the manuscript that addresses points raised during the review process

Please submit your revised manuscript by Dec 19 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-emailutm_source=authorlettersutm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Darrell Eugene Singer, M.D., M.P.H.

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.

Additional Editor Comments:

Your paper will be reconsidered for publication after you address the comments of the editors and peer reviewers and revise the manuscript as appropriate. This request for a revision is not a guarantee the manuscript will be accepted.  The final decision concerning publication will be based on the quality of your responses and the revised paper.  We encourage your review the entirety of both reviewers' comments (below), however, please respond only to the following specific points:

4. Have the authors made all data underlying the findings in their manuscript fully available?

-We appreciate the amendments to this area made by the authors under the first revision request.  The PLOS staff will subsequently determine any final data sharing requirements. (No response required).

6.  Review comments to author(s):

Abstract:

-Please address the grammatical error in the first sentence.  Suggest changing “Efforts were focused on identify” to “Efforts were focused on identifying” (Edit or response required)

-Please indicate the primary analysis for findings (e.g., Hazard or Rate Ratios) and the confidence intervals for each (Edit or response required)

Introduction

-When referring to indigenous American populations, the best practice is to define specific groups when using the terms "American Indian" and "Alaska Native", and/or the abbreviation “AI/AN.”  Example- authors write “American Indian/Alaska Natives [AI/AN]” in the last sentence of the first paragraph.  Recommend amending to 'American Indian/Alaska Natives [AI/AN] populations' (or individuals, persons, service members) as is used in the remainder of the paper (e.g., in the second paragraph of the introduction, "...AI/AN individuals." (Edit or response required)-

-The statement referring to “…these findings suggest that investigation into subgroups of racial/ethnic military members/Veterans at elevated risk for suicide...”, suggest amending to (or similar) '…these findings suggest that investigation into suicide rates among racialized minorities in the military should consider if...'.  (Edit or response not required but recommended)

- "Veteran" is only capitalized at the beginning of a sentence or specific proper nouns (people, groups, places, etc.).  https://www.legion.org/sites/legion.org/files/legion/publications/Legion-Publication-Style-Guide.pdf  (Edit or response required)

- "Department of Defense (DoD)" is spelled out and abbreviated/defined as an acronym twice in the introduction, then spelled out or abbreviated multiple times in the remainder of the manuscript.  Recommend editing for consistency.  (Edit or response required)

Methods:

-Consider describing the criteria which were used for age classifications.  (Edit or response not required but recommended)

-Consider adjusting for gender as well given the generally higher risk of suicide among men (across populations) compared to women?  If not, consider adding to the discussion section. (Edit or response not required but recommended)  - Recommend adding p-values to Table 1. (Edit or response required)

- Recommending adding hazards and mortality-related suicide (Yes/No) by component. (Edit or response not required but recommended)  

Results:

-Reviewer 1 states "The American Indian/Alaskan Native cohort showed a higher suicide rate, but the lower 95%CI (1.02, 2.13) is almost 1.0. This group is quite small so I would combine it with the “other” race group."  Out of interest in identifying risks to specific groups, it is understandable to maintain separation; however, discussing the limitation of the group size and subsequent confidence interval is appropriate in the discussion section.  (Edit or response not required but recommended)  

Discussion:

-Consider discussing the inability to assess suicidality trends among AI/AN person over time.  (Edit or response not required) 

-Reviewer #2 states: "Given the authors’ exposure of interest is race, they would benefit from using the Lett et al. article cited in the discussion to help contextualize their findings. Specifically, the authors should say more in the discussion about the potential structural factors that may influence inequities in suicide among racialized minorities in the military."  (Edit or response not required)  

[Note: HTML markup is below. Please do not edit.]

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: (No Response)

Reviewer #2: (No Response)

********** 

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

********** 

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: No

********** 

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

********** 

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 this study, Brenner et al. detail the suicide rate among United States Army members who returned from an index deployment with respect to race/ethnicity and age. It is an important contribution for suicide prevention in this population. I would like to raise some points:

Abstract: Rate ratios and confidence intervals must be present.

Methods: My main concern is the way the methods section is written. Please describe the criteria which were used for age classifications. How were hazards for suicide evaluated? Do the authors have any data on psychiatric disorders, mental health visits, or repeated attempts?

Results: The American Indian/Alaskan Native cohort showed a higher suicide rate, but the lower 95%CI (1.02, 2.13) is almost 1.0. This group is quite small so I would combine it with the “other” race group.

Additional analysis to consider for Table 1:

Add p-values.

Add hazards and mortality-related suicide (Yes/No) by component.

Discussion: Asian, Hispanic, and Black veterans were at decreased risk compared to White veterans, regardless of age. Could you confirm these relationships with the support of previous studies?

Reviewer #2: General comments

This retrospective cohort study used the SUPIC database to identify differences in suicide rates and time-dependent hazard rate trends by race and ethnicity among US Army members after index deployment. The authors found that AI/AN persons ages 18-29 had increased risk for suicide compared to WNH persons.

This is an important area of study, as there are limited data on racial inequities in suicide rates in the military. Overall, the study is well designed, straightforward and presented clearly. I do think there are a few minor changes, particularly in the framing of the discussion, that would strengthen the paper.

Abstract

1. Change “Efforts were focused on identify” to “Efforts were focused on identifying”

Intro

1. Best practice is to not let American Indian/Alaska Native or AI/AN stand alone in the body of the paper. Authors write “American Indian/Alaska Natives” in the last sentence of the first paragraph (I believe this is the only time). Instead, suggest “AI/AN people,” “AI/AN persons,” etc, as is used in the remainder of the paper.

2. The authors write that “…these findings suggest that investigation into subgroups of racial/ethnic military members/Veterans at elevated risk for suicide...” Suggest changing to ““…these findings suggest that investigation into suicide rates among racialized minorities in the military should consider if...”

3. DoD is abbreviated multiple times in the intro

Methods

1. Did authors consider adjusting for gender as well given the generally higher risk of suicide among men (across populations) compared to women?

Results

1. see table/figure comment

Discussion

1. Given the authors’ exposure of interest is race, they would benefit from using the Lett et al. article cited in the discussion to help contextualize their findings. Specifically, the authors should say more in the discussion about the potential structural factors that may influence inequities in suicide among racialized minorities in the military.

Tables/figures

1. Can the authors speak more about the inability to assess suicidality trends among AI/AN person over time? It would be nice to see the gross trends over time even if the numbers aren’t large enough to run analyses. At minimum, it seems like this should be added to the limitations section of the paper.

********** 

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: Anwar E. Ahmed

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.

Trends in Suicide Rates by Race and Ethnicity among Members of the United States Army

PONE-D-22-19049R2

Dear Dr. Brenner,

We are 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,

Darrell Eugene Singer, M.D., M.P.H.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dr. Brenner: Congratulations!  Thanks to you and your co-authors for your efforts, patience and this important contribution.  Happy Holidays to you and yours.  Best regards, DS