PONE-D-23-04252

Can routine assessment of older people’s mental health lead to improved outcomes: A regression discontinuity analysis

PLOS ONE

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PLOS ONE

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Additional Editor Comments:

The reviewers feel that the manuscript is well-written, but needs to undergo minor revisions. For example, they suggest that you state your hypothesis and/or research questions in the introduction section and provide a more comprehensive discussion of the importance/benefit of screening for depression in primary care settings. Please find the detailed comments appended below.

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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: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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: No

Reviewer #3: No

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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

Reviewer #3: 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: Important note: This review pertains only to ‘statistical aspects’ of the study and so ‘clinical aspects’ [like medical importance, relevance of the study, ‘clinical significance and implication(s)’ of the whole study, etc.] are to be evaluated [should be assessed] separately/independently. Further please note that any ‘statistical review’ is generally done under the assumption that (such) study specific methodological [as well as execution] issues are perfectly taken care of by the investigator(s). This review is not an exception to that and so does not cover clinical aspects {however, seldom comments are made only if those issues are intimately / scientifically related & intermingle with ‘statistical aspects’ of the study}. Agreed that ‘statistical methods’ are used as just tools here, however, they are vital part of methodology [and so should be given due importance]. I look at the manuscript in/with statistical view point, other reviewer(s) look(s) at it with different angle so that in totality the review is very comprehensive. However, there should be efforts from authors side to improve (may be by taking clues from reviewer’s comments). Therefore, please do not limit the revision only (with respect) to comments made here.

COMMENTS: Although this manuscript is well drafted [and the study is excellent with respect to most of the aspects], I have few observations/concerns (different opinion) which are given below:

Firstly, {although on one hand I must congratulate and appreciate authors having used this design} it may please be noted that the RD (regression discontinuity) design lacks the random assignment feature. In addition to this, there are several issues* that disallow a status equal to the randomized experiment and the RD design has to be classified as a quasi-experimental design.

Few of the issues described in literature are:

- it is a new design and not yet as clear as the randomized experiment.

- the RD design heavily depends on correctly modeling the functional form of the relationship between the assignment variable and the outcome variable. Therefore, in order to obtain unbiased estimates, more sophisticated statistical analyses are required than is usual in experimental settings.

- the RD design has less power than the randomized experiment. This is mainly due to multicollinearity between the assignment and treatment variable. The loss of power is greater the more the cutoff deviates from the mean of the assignment variable. When nonlinear effects (e.g., interaction and quadratic effects) are present, multicollinearity increases as well as reduces the power of the design. In order to increase the power to 0.80, the RD design needs up to 3 times as many participants as a randomized experiment

Though sometimes the argument(s) made that “from a methodological point of view, inferences which are drawn from a well-implemented RD design are comparable in internal validity to conclusions from randomized experiments” it is not very convincing. It is often said that, in principle the RD design is as strong in internal validity as its randomized experimental alternatives, however, in practice, the validity of the RD design depends directly on how well the analyst can model the true pre-post relationship, certainly a nontrivial statistical problem.

The real allure of the RD Design is that it allows us to assign the treatment or program to those who most need or deserve it. Thus, the real attractiveness of the design is ethical – we don’t have to deny the program or treatment to participants who might need it as we do in randomized studies.

With this background information I have, few questions are raised in mind [though they may appear to be silly on prima-facie, you need to clarify these things because mind you that this is a scientific/academic document and so all details should be clearly/correctly communicated (do not take readers’ for granted)].

• As per line 26 [Design] data are from a randomised controlled trial. My question is {though in lines 142-143 it is stated that adjustment for covariates included that for participant’s REFORM trial allocation}, participant’s those who are randomly allocated to intervention arm of REFORM trial are already influenced/affected by that intervention [those who are randomly allocated to control arm (even if active control or placebo) of REFORM trial are already influenced/affected differently] then will it likely to affect your outcome.

• There may be substantial period between ‘baseline’ reading time and your intervention. What about that?

Section ‘Study Design and Statistical Methods’ in lines 106 onwards is fairly well drafted but authors may think including above (and/or other such) points. I agree with the ‘Limitations’ part highlighted/enumerated in lines 260 onwards [but not so much with ‘Strengths’ part of the section].

Except these minor points, the article is acceptable. However, mind you that as pointed out in ‘important note’ above “This review pertains only to ‘statistical aspects’ of the study and so ‘clinical aspects’ should be assessed separately/independently.

Reviewer #2: The study is well structured and described in the manuscript, and I think it brings important and insightful contributions regarding ways to improve mental health assistance to the older population. However, I made some suggestions and recommendations detailed in the manuscript's comment boxes, attached to this review. Basically, I suggest the authors (1) to state their hypothesis and/or research questions in the introduction; (2) to justify why they chose to run the sharp version of RDD; (3) to describe other instruments and questionnaires used along with the GDS-15 to collect data, especially those described in the results; (4) to revise Table 1, there are many points to pay attention. I recommend running statistical analyses to check for significant differences between groups in the results in Table 1. There is no information in methods about the instruments displayed in Table 1, so the reader can't interpret appropriately the results. I recommend you remove this data from the table or describe the instruments in the methods and how we interpret them. The sum of the cases for gender in Table 1 needs to be revised, it does not match. Please, specify what BMI means; (5) In Table 2 you need to highlight the cells of "during the past 4 weeks, have you worried about a fall" to indicate there was a significant difference between groups; (6) The results must be interpreted taking into account the sociodemographic background of the sample, and I think that authors should go deeper in this matter in the discussion

Reviewer #3: I found the paper to be very interesting. The authors adequately described and analysed their findings. While the effect of the intervention (1.1-point reduction) may not be clinically significant, the authors have provided appropriate context and reported on the uncertainty of it in the discussion section. The paper is somewhat concise, it is well written. I do have a few suggestions for the authors:

(Introduction) It would be helpful to provide a more comprehensive discussion on the importance/benefits of screening for depression in primary care settings.

(Methods/Results) It is not clear when the data were collected, which could be clarified in the methods or results section.

(Methods) It would be informative to include data from the second follow-up assessment (12 months) to evaluate the long-term effects of the intervention.

(Results) It would be helpful to report means and medians of GDS-15 scores in both groups (<10/10+) at baseline and 6 months to provide readers with a better understanding of the true effect of the intervention.

(Results) Including information about depression treatment, if available, would be useful. If such information is not available, the authors should acknowledge this as a limitation of their study.

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Reviewer #1: No

Reviewer #2: Yes: Heloisa Goncalves Ferreira

Reviewer #3: No

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Can routine assessment of older people’s mental health lead to improved outcomes: A regression discontinuity analysis

PONE-D-23-04252R1

Dear Dr. Baird,

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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Vanessa Carels

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

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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: (No Response)

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

Reviewer #1: (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)

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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: (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: COMMENTS: All the comments are answered and most positively attended [I appreciate that many desired changes are made, especially the design details added]. I recommend the acceptance because the manuscript has now achieved the acceptable level (even earlier also I said: except highlighted minor points, the article is acceptable} in my opinion.

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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

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