PONE-D-24-12316Unlocking the mentally ill in Indonesia: An empirical study of the effectiveness of a “Bebas Pasung” program in Central JavaPLOS ONE

Dear Dr. Tyas,

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 Jun 07 2024 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-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ashish Wasudeo Khobragade, MD

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

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

2. Thank you for stating in your Funding Statement:

‘”This research is supported by USAID Cooperative Agreement No. AID-497-A-11-00017, "Inter-University Partnerships for Strengthening Health Systems in Indonesia: Building New Capacity for Mental Health Care" (https://www.usaid.gov/id/indonesia ). This was a USAID Cooperative Agreement with Harvard Medical School, with BJG as Project Director and MJDG as Co-Project Director. Subcontracts to Gadjah Mada University, with MA Subandi (MAS) and Carla R. Marchira (CRM) as Principal Investigators, supported research activities in Yogyakarta from 2011 through 2014. Data analysis and writing was partially supported by a grant to the Department of Global Health and Social Medicine from the Harvard Medical School Center for Global Health Delivery--Dubai, for a project entitled "Building a Model for Comprehensive Mental Health Care in Yogyakarta, Indonesia." Harvard Principal Investigators were BJG and MJDG. Work in Indonesia was supported by a consortium agreement with Gadjah Mada University, with MAS and CRM as Principal Investigators. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

Please provide an amended statement that declares *all* the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now.  Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement.

Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf.

3. In the online submission form you indicate that your data is not available for proprietary reasons and have provided a contact point for accessing this data. Please note that your current contact point is a co-author on this manuscript. According to our Data Policy, the contact point must not be an author on the manuscript and must be an institutional contact, ideally not an individual. Please revise your data statement to a non-author institutional point of contact, such as a data access or ethics committee, and send this to us via return email. Please also include contact information for the third party organization, and please include the full citation of where the data can be found.

4. 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 (if provided):

It is my pleasure to evaluate the manuscript titled “Unlocking the mentally ill in Indonesia: An empirical study of the effectiveness of a “Bebas Pasung” program in Central Java”. In this manuscript, the effectiveness of the 'Bebas Pasung' program is studied by the authors. The manuscript is interesting and of public health significance, but it requires revision.

1. The total number of tables in the manuscript is 16. Findings from some tables (those with fewer rows and columns) can be mentioned in the result section so that the number of tables can be reduced. Cite all the tables within the text.

2. The statistical tests used are not mentioned in the manuscript. Information on statistical analysis is missing in the methodology section.

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

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

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

**********

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

**********

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: 1. Is the manuscript technically sound, and does the data support the conclusions?

The manuscript appears to be technically sound. It describes a rigorous empirical study evaluating the effectiveness of the Bebas Pasung program in Central Java, Indonesia, for individuals with severe mental illness. The methods employed for data collection, including interviews with caregivers and analysis of hospital records, seem appropriate and thorough for the study's goals. The results, which provide descriptive data on patients' histories, reasons for confinement, types of confinement, and caregivers' experiences, support the study's conclusions. The study successfully demonstrates that the program has been effective in unlocking, treating, and reintegrating individuals with severe mental illness back into their communities. Furthermore, the manuscript outlines the program's strengths and weaknesses, showing a balanced view supporting the conclusions drawn.

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

The manuscript includes detailed statistical analysis, particularly in the results section, where scalar data from caregivers is presented. Using mean differences and p-values to assess changes in caregivers' experiences of shame, economic burden, psychological distress, family relationships, and overall spirit indicates a rigorous statistical approach. However, the manuscript could benefit from more detailed information on the statistical methods used for analysis, such as specific tests performed. The statistical analysis seems appropriately performed and supports the study's findings.

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

The manuscript details the data collection process from hospital records and caregiver interviews, providing a solid foundation for the findings presented. However, it does not explicitly state if all the raw data underlying the findings, such as interview transcripts or detailed hospital record data, are fully available for external review. For transparency and to strengthen the study's credibility, the authors should clarify the availability of the underlying data.

4. Is the manuscript presented in an intelligible fashion and written in standard English?

The manuscript is well-structured, with transparent sections for the abstract, introduction, methods, results, discussion, and conclusions. Using tables to present data enhances readability and the understanding of critical findings. The manuscript is written in standard English, with a formal tone appropriate for a scientific audience. Minor editorial revisions could further refine the manuscript's clarity and presentation quality.

Summary and Recommendations

The manuscript provides a valuable contribution to the field of mental health, particularly in the context of community-based care for individuals with severe mental illness in low-resource settings. To strengthen the manuscript further, the authors could consider:

• Providing more detailed descriptions of the statistical methods used.

• Clarifying the availability of underlying data for review by others.

• Undergoing minor editorial revisions for clarity and presentation quality.

Overall, the manuscript meets the criteria for a technically sound piece of scientific research, with data that support the conclusions drawn.

Reviewer #2: Thank you for the opportunity to review this manuscript. I am pleased to provide my feedback on this insightful and valuable piece of research.

The topic of the manuscript is highly significant and addresses an under-discussed issue within international mental health care, specifically the practice of pasung in Indonesia. The authors have highlighted a crucial social and health issue that remains largely hidden from the international community. The study not only sheds light on the challenges and needs of persons with severe mental illness who have been subjected to confinement but also emphasizes the transformative impact of Indonesia's Bebas Pasung program.

I commend the authors for their diligent efforts in collecting and presenting data from a difficult-to-reach population. Their findings provide a meaningful contribution to our understanding of the longitudinal outcomes for those affected by severe mental illness after their release from confinement. The descriptive data offered about the history of illness, reasons for locking, and types of confinement enriches the discourse on mental health services in culturally diverse settings.

Additionally, I am personally grateful for the opportunity this review process has afforded me to learn and understand more deeply about the phenomenon of pasung. Reading this manuscript has been truly enlightening. I believe its publication will significantly benefit the broader psychiatric community by illuminating a previously obscured aspect of mental health care in a unique setting. Parallels to similarly tragic issues are faced also in Western contexts, now and in the past, underscoring the global relevance of this research.

I fully support the publication of this manuscript. It is an important contribution that not only informs but also prompts important discussions and potential policy changes in the treatment of mental health globally.

I have a few suggestions that could further enrich the discussion and implications of your findings:

- Could you provide a brief explanation of the Bebas Pasung policy, focusing on its legal, administrative, and organizational aspects, in the introduction?

- Could you elaborate on how your data might be interpreted within the broader context of potential future interventions aimed at enhancing compliance and preventing re-locking?

- Based on your data, what types of support or interventions do you suggest could be implemented to improve both the family's circumstances and patient outcomes?

- Is it possible to compare your findings with data from a "typical" psychiatric population within your country to highlight any unique trends or differences?

- Are there more socio-economic data available about the families involved in the study that could be shared?

- Do you have additional clinical data about the studied population that you could share (e.g. CGI-S scores at program entry and CGI-I scores at exit)?

- Additionally, would it be possible to anonymize the data using a feasible method to facilitate sharing with fellow researchers?

Also, to enhance the methodological rigor of your results, I suggest incorporating a brief statistical methods paragraph that outlines the statistical significance tests you've conducted.

Thank you once again for the opportunity to review this significant work. I look forward to its publication and the continued dialogue it will undoubtedly inspire within the mental health community.

Best regards

**********

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

Reviewer #2: Yes: Pierfelice Cutrufelli

**********

[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.

Unlocking the mentally ill in Indonesia: An empirical study of the effectiveness of a “Bebas Pasung” program in Central Java

PONE-D-24-12316R1

Dear Dr. Tyas,

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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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,

Ashish Wasudeo Khobragade, MD

Academic 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

**********

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: Yes

**********

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: Introduction and Background: The background information on the historical and cultural context of pasung in Indonesia is comprehensive. The discussion on the policy developments and the Bebas Pasung initiative provides a clear understanding of the study's importance.

Methods: The methodology is robust, with clear descriptions of the sample selection, data collection, and analysis processes. The use of both qualitative and quantitative methods enriches the study's findings.

Results: The results section is detailed, providing valuable data on the demographics of the participants, the types of confinement, and the outcomes of the program. The use of tables to present scalar data on the caregivers' experiences before and after the program is effective.

Discussion: The discussion effectively interprets the findings, highlighting both the strengths and weaknesses of the program. The comparison with similar programs in other countries, such as China, adds depth to the analysis.

Limitations: The authors acknowledge the study's limitations, including the potential for selection bias and the inability to conduct direct evaluations of current psychiatric symptoms at the time of follow-up. This transparency is commendable.

Recommendations: The recommendation for integrating unlocking programs with comprehensive community-based mental health services is well-founded. Future studies could explore long-term outcomes and more extensive follow-up to build on the findings presented here.

Data availability: I am aware the authors have attempted to make the underlying data available ("Interview transcripts and detailed hospital record data cannot be made available due to sensitive information that may jeopardize the identity of participants. However, data on the specific variables in this study are available upon request." I will leave this up to the editor to justify if this is appropriate enough for publication.

On all other accounts, this is a valuable and well written manuscript.

Reviewer #2: Dear Authors,

I am personally satisfied with the status of the revised work. Thank you for the insights regarding the psychiatric situation in analogous contexts in the West. It is important to highlight that stigma and marginalization are culturally influenced, but not culturally defined; unfortunately, no culture is exempt from perpetuating them.

Regards.

**********

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: Harry James Gaffney

Reviewer #2: Yes: Pierfelice Cutrufelli

**********