PONE-D-22-29913Implication of Insomnia and Depression Among Malaysian Undergraduate Health Science University Students in UPM During Covid-19/Movement Control OrderPLOS ONE

Dear Dr. Bin Raja Yahya,

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Academic Editor

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Reviewers' comments:

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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: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: I Don't Know

Reviewer #4: Yes

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: 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: Thank you for shedding light on this topic. This paper has a remarkable potential to bring this issue into the mainstream through PLOS, but I suggest some minor revisions.

The sample demographics are markedly skewed regarding gender (female>> male). The sample likely reflects the heterogeneous nature of the study population.

By design of its proposed testing methodology, PHQ-9 captures symptomatology over the past fourteen days, which varies significantly based on interrater reliability. Consider commenting on inter-rater reliability in the methodology section.

The introduction is well-framed and discusses Depression and Insomnia in terms of clinical presentation, known etiology and neurobiology.

Paper could benefit from adding any specific resources, if they exist (CDC, AACAP, AAP, APA, etc.), that clinicians can access to learn more on it or seek guidance.

Reviewer #2: This is a cross-sectional study performed to examine a relationship between undergraduate students' level of depression, insomnia during lockdown in Malaysia. This well-done study identifies several key features that can allow clinicians to identify risk factors among undergraduate students in order to diagnose and treat mental health issues. The study appropriately identifies the limitations it has. The conclusion section of the article can be further modified in order to provide concrete, actionable knowledge that can be acted upon by governments and universities to further help their students.

This study does not provide context in regard to the COVID-19 pandemic in Malaysia in the introduction section. While COVID-19 pandemic affected the entire globe, every country had their own individual experiences with COVID-19 spread. Some countries had an exceptionally severe first wave, while others had a terrible second wave. The authors can improve this article by providing context about how COVID-19 pandemic played out in Malaysia. The same can be said about race and different regions of Malaysia from which the students come from as western readers will be unsure what differentiates one region and race of Malaysia from the other socio-demographically. This will give readers further information about whether the undergraduate students were prepared to face the challenges they will face if COVID-19 spreads in their country.

Another concern observed is the lack of discussion of adjustment disorder with depressed mood and acute stress disorder as differential diagnoses for these students. COVID-19 pandemic can be looked at as a significant event, which can lead to depressive features in an individual who is unable to adjust to this significant change in their lives.

The second paragraph of discussion compares the higher rate of insomnia in students in the United States with the findings of the study. The authors can further discuss the difference in the US study to that in Malaysia in order to further explore the reasons behind this difference in students being affected.

The authors can also consider adding references to allow Western readers to understand the differences between races in Malaysia in order to appreciate the third paragraph of discussion.

The authors identify and discuss excessive use of screens late at night as an issue leading to insomnia. They can also consider discussing the COVID-19 related increased social media usage being a cause. The initial wave of the pandemic was associated with an "infodemic" of fear mongering and harmful misinformation propagated from social media. This led to a lot of people falling victim to quackery and unscientific methods. This was also politicized in many different countries all over the globe, and it gave rise to conspiracy theories and echo chambers where people magnified each other's anxiety and paranoia.

Reviewer #3: The study raises important questions about impact of COVID on the depression and insomnia, on the students. The does have some limitations as to it is unclear, how that the impact of Covid on the outcome measures is assessed. The conclusion talks about female gender, Bumiputra, and people living alone being more at risk of depression and insomnia, although it might be helpful to know how much different was the data, pre covid and post covid for these populations. It does raise awareness about importance of mental health support for college students, through social media, support groups and generating awareness through internet.

Reviewer #4: Hello. Thank you for submitting your manuscript for review. It was a good read and interesting to note the conclusions/ results you had. I had only certain minor suggestions:

1) Page 2 - "The most prevalent condition in terms of depression among teenagers and young adults

is Major Depressive Disorder (MDD)" - The most prevalent condition is MDD? I suspect that there might be less severe depressive symptoms that might be more prevalent.

2) Page 2-"One of the key factors that contribute to efficient cognitive and emotions process has

been sleep. Insomnia is a risk factor for both gender and age, with older adults and

women being more likely to experience insomnia." - Both of these sentences can be reworded to be more grammatically accurate. e.g. processing instead of process; Insomnia is a risk factor? or probably better called- older Age and female gender are risk factors for insomnia.

3) Page 3 - "In addition, anxiety and insomnia also can cause depression [21, 23]. According to Akram

et al. [24], anxiety symptoms can make it harder to fall asleep by increased the

rumination (which may be related to the stress of academic life for students)." Please change increased to increasing

4) In results (Chart in page 16) - I'm curious why were 'mild/ moderate insomnia' not listed and were considered 'subthreshold insomnia'.

5) In discussion (page 17)- I can see how you are comparing the rates you had with rates in studies done elsewhere but you can't really compare those studies because of various different confounding factors in those samples. Since you had a study from similar population from by Sundarasen S, et. al., that could have been a better comparison. Although I don't think you took any significant conclusion from this comparison as such.

6) Could you discuss why Bumiputra students in this study had more likelihood of having depression.

7) What was the purpose of discussing rumination as a separate entity when your data uses PHQ-9 and ISI and does not measure rumination among the population you studied?

Again,

Thank you for giving us the opportunity to review your work and putting so much effort into studying and writing it.

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Reviewer #1: No

Reviewer #2: Yes: Lakshit Jain MD

Reviewer #3: Yes: Meenal Pathak

Reviewer #4: No

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Implication of Insomnia and Depression Among Malaysian Undergraduate Health Science University Students in UPM During Covid-19/Movement Control Order

PONE-D-22-29913R1

Dear Dr. Bin Raja Yahya,

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Kind regards,

Ankit Jain, M.D.

Academic Editor

PLOS ONE