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PONE-D-23-00898Mental health during a pandemic: Characteristics and experiences of clients accessing a walk-in mental health clinicPLOS ONE

Dear Dr. Wellspring,

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.

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Academic Editor

PLOS ONE

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Additional Editor Comments:

Dear Dr. Wellspring,

Thank you for your submission to PLOS ONE.

Reviewers have now commented on your paper. The manuscript requires major and significant revisions. If you are prepared to undertake the work required, we would be pleased to reconsider sending your revised manuscript for a review. For your guidance, the reviewers' comments are attached. If you decide to revise and resubmit the manuscript, please include a detailed cover letter explaining which specific changes you made and which recommendations you did not follow and why. This letter should address all of the points raised by each reviewer.

Once the paper has been revised, submit it through the manuscript submission portal.

Sincerely,

Yaara Zisman-Ilani

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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: Partly

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

Reviewer #1: Yes

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: No

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: Thank you for the opportunity to review this manuscript that addresses the topic of COVID-19 effects on mental health, which is still a pressing issue that requires more understanding and addressing. The efficacy of IPC/WIWC is also interesting and can offer a solution to existing gaps in mental health services. The mixed-methods approach provides a broad view of clients' experiences. However, I find that the paper presents two completely different subjects (1. Mental health during and before COVID-19; 2. Clients' satisfaction with WIWC/IPC), and although the authors try to link them in the discussion, they are presented as separate through most of the manuscript and also in the study's procedure (since the feedback forms are not dated, COVID-19 associations with clients' satisfaction were not explored). Therefore, I think the authors should consider removing the parts about clients' feedback regarding WIWC (perhaps presenting them in a different paper), and focusing only on mental health before and during COVID-19. This was the most pressing concern, and it caused confusion throughout the manuscript, from the title to the discussion.

Below I provided more thoughts and feedback, which I hope will be of help.

Title:

1. The title of the paper should be reconsidered. After reading it, I expected that the focus would be mental health during the pandemic. I didn't expect such a large volume about IPC itself (especially in the introduction). I recommend rethinking the title so that it better reflects the content of the paper, or as I suggested above, reorganizing the paper so it includes only one of the subjects.

Abstract:

2. The study aims should be included before describing the CAT-MH.

3. The sentence "Profile analysis indicated a significant difference in mental health profiles" should be made clearer and more accurate to the results it describes. It is the first sentence to describe the main result, so it should be clear and simple.

4. The paper reports a surprising finding: lower depression scores and higher suicidality flags. It should be acknowledged and explained (in the discussion, but also in the abstract) that these two findings together are unexpected.

5. Please remove the word "the" in "the private donors" under financial disclosure.

6. In the last sentence, please use the full term "Integrated Primary Care (IPC)" as it is the first time this abbreviation is mentioned.

Introduction:

7. In general, there is a lot of information here about IPC and not enough about mental health during the pandemic. The title and abstract focused on mental health during COVID-19 and then the introduction only describes it in one paragraph after discussing IPC for two pages. This is confusing.

8. In line 112, I suggest replacing "endorsing" with "reporting".

9. In lines 119-121, I think you should mention that therapists' transition to videoconferencing therapy is usually due to government restrictions during the pandemic.

10. Lines 124-152 (describing the CAT-MH) belong in the METHODS>>MEASURES section.

11. Similar to the previous comment, lines 153-164 (describing the WIWC) belong in the METHODS>>PARTICIPANTS, especially since most of the content already appears in the PARTICIPANTS section.

12. I found it confusing that after such a long description of IPCs, the study took place in WIWC, which lacks the "bridge" element between physical and mental health care. Therefore, I suggest removing or narrowing the part describing the benefits of IPC by highlighting the collaboration between the physician and mental health provider and the reduction of stigma.

13. There is a gap between the OBJECTIVES & HYPOTHESES section which focuses on persons' mental health during COVID-19, and the INTRODUCTION which focuses on the efficacy of IPC. To better reflect the objectives, I suggest again narrowing considerably the IPC part in the introduction and representing more fully the effects of the pandemic on mental health (for example, citing studies not just from Canada, adding literature about mental health during previous pandemics). In general, I recommend clarifying what is already known, what the knowledge gaps are and then using this to justify the study rationale.

14. I don't understand how the two objectives are related. It seems to me that these are two completely different subjects: 1) mental health during COVID-19. 2) Clients' satisfaction with the WIWC. Because the feedback forms are without dates and thus don't allow for a comparison between before and during the pandemic, I think it will be better to remove the second objective and focus this paper only on mental health during the pandemic.

Methods:

15. When describing participants and the WIWC, please elaborate more about the nature of the intervention offered. For example, what kind of professionals work there, how many sessions are offered, what kind of therapeutic approaches are used?

16. Please specify the dates of data collection.

17. Please clarify does each provider read the patient's CAT-MH results before the session? Namely, is the CAT-MH used so that providers will know which issues to focus on during the current session?

18. In line 242, the authors use an example of coding overall severity scores. Why does the researcher need to code severity if "the CAT-MH produces an overall severity rating" (line 234)?

19. Regarding feedback forms, for clients who attended the services more than once, how many forms were analyzed? One or more?

Analysis:

20. The description of the form's open-ended questions (lines 269-274) belongs in the MEASURES section. There is a need for clarification because in the MEASURES>>FEEDBACK FORM section the authors write that the form includes one open-ended question and three multiple-choice questions. Then in the ANALYSIS PLAN section the authors write that the form includes other open-ended questions.

21. The authors report having 693 records and 216 feedback forms of these records being analyzed. How was it decided which feedback forms to analyze?

Results:

22. Again, I think the whole part about treatment satisfaction should be removed (and perhaps reported in a separate paper). However, if you stick to it as is, please make sure that throughout the paper the two subjects appear in the same order. For example, you start the introduction and objectives with the COVID-19 issue, but you start the results with the satisfaction issue. This is confusing.

23. In line 292, satisfaction with what? Treatment? Please specify.

24. How do you explain the gap between suicidality scores presented in the table (where during COVID the score is a little lower than the score before Covid), to the difference in suicidality flags according to chi-square?

25. I suggest presenting the results not according to quantitative/qualitative, but according to the two study objectives.

26. In line 391, I suggest deleting "Fig 2 highlights that" and instead starting the sentence with "Clients were appreciative…".

27. In INFORMATIONAL SUPPORT, it would help if the reader knows what kind of techniques/plans were offered by providers. Otherwise, it sounds vague. This relates to comment no. 15.

Discussion:

28. The sub-titles should be broader. For example, instead of CAT-MH >>> MENTAL HEALTH BEFORE AND DURING COVID-19.

29. The inconsistency between the results of this study and other studies regarding depression is not well explained.

30. In lines 423, 425, please delete the word "for" in "for before the COVID-19…".

31. In line 440, the sentence "as well as how the questions are phrased on the CAT-MH" belongs in the next paragraph and not here.

32. The explanation regarding creativity seems far-fetched since the study didn't ask about clients' creative activities during or before the pandemic.

33. Please rephrase lines 459-462. It is not clear enough. For instance, in line 461, "higher" than what?

34. In line 482, what do you mean by "reduced responsibility"? Lines 482-487 don't seem to be related to the subject described in this section.

35. The possibility that people may feel more comfortable disclosing suicide ideation via videoconference is interesting. However, the authors didn't address the dissonance between the two findings reported here (lower depression scores and higher suicidality flags). This should be addressed and attempted to be explained.

36. In CLIENT FEEDBACK (which also should be replaced with a broader title), the first sentence should be removed.

37. In line 493, the sentence starting with "While no single…" is not clear.

38. In lines 505-506, the authors write "…directly influenced their opinions of IPC". The cited paper reports an association, not a causal relationship. Please rephrase.

39. Under LIMITATIONS, when the authors write about the lack of demographic data, I suggest addressing also the difficulty of generalizing or reaching general conclusions.

40. In lines 534-535, I think the PAI and MMPI are not relevant here, as they are both very long and time-consuming.

41. Can you highlight the added contribution of this study to the research literature?

42. Are there specific recommendations arising from these data?

Conclusions:

43. In line 562, please change "within" to "among".

44. I think this section needs more work. Specifically, the two subjects of the study (mental health during and before covid and satisfaction from WIWC) are intertwined here and should be separated. For example, in lines 574-576 the authors write about the effectiveness of services "both before and during COVID-19". However, since the feedback forms were not dated, referring to before and during COVID here is irrelevant.

References:

45. References no. 77,78 are the same reference.

Reviewer #2: The authors present findings from Computerized Adaptive Testing -- Mental Health (CAT-MH) at intake of a outpatient mental health clinic as well as thematically coded findings from open-ended questions and 3 scaled satisfaction questions completed after their (seemingly first, but this is not obvious from description) session both prior to onset of COVID and during COVID (November 2018 to March 11, 2020 and March 11, 2020, to June 2022, respectively). They describe two objections: 1) "to utilize CAT-MH data to measure the nature and severity of mental health concerns of clients who accessed a walk-in mental health clinic before and during the COVID-19 pandemic" and 2) to explore clients experiences with the walk in clinic through qualitative analysis of the open-ended questions (and given what they report, apparently also quantitative analysis of the 1-100 scales).

Regarding (1), they hypothesized that that depression, anxiety, suicidality, and substance use subscales of the CAT-MH would be worse for those presenting after COVID. In contrast, they present the interesting finding that the only means on subscales of the CAT-MH for the pre-COVID group and the during COVID group were not significantly different, with the exception of the depression subscale, where the pre-COVID group scores reflected significantly greater depression subscales.

Regarding (2), they present findings that the mean score (1-100) for finding the service helpful was 83.33, that for finding the service to address the clients concerns was 82.47, and that for overall satisfaction was 88.22--all reflecting high client satisfaction. They also present thematic findings on open-ended questions that clients found the service to be emotionally supportive; that the interventions to include helpful components (which they label "informational support," but for which many themes do not obviously have to do with providing particular types of information [e.g., that this "was a great way to 'break the ice'"); that clients identified "logistical considerations that appear to reflect reduction in barriers to accessing care' and that concerned limitations of the service (e.g., that it was too brief in length).

The authors conclude that "taken together, the results demonstrate the effectiveness and efficacy of services modeled on IPC in reducing barriers to accessing mental health care, both before and during the COVID-19 pandemic. The results further illustrate that IPC is a viable service delivery model to mitigate the challenges experienced by the healthcare system that merits further investigation and consideration. There are other important and integral research areas to consider, including the long-term effectiveness of IPC [i.e., Integrated Primary Care]."

The finding regarding depression is interesting and the exploratory findings are suggestive. However, the paper suffers from several flaws:

1) The intervention is not IPC. The authors briefly note this on p. 8, lines 188-192. There they write: "It should be noted that the WIWC is modeled on the principles of IPC, but it in and of itself is not an integrated primary care clinic as only mental health professionals provide services. However, the WIWC has fostered various relationships within the Okanagan community and actively collaborates with other service providers to ensure ease of services." The authors do not provide a detailed description of the nature of the walk-in clinic and certainly do not operationalize its model robustly. They do note that services were virtual during the pandemic and they do describe the clinic model as follows: "short-term solution-focused mental health support is offered to individuals who are often referred by family physicians, walk-in medical clinics, or other community organizations, despite an absence of colocated care."

However, this does not appear sufficient to warrant the claim that this is sufficiently like IPC or any adaptation of IPC for their findings to be informative about IPC. They note that sessions are 30 minutes in discussion of the thematic analysis, and they also note in that section that typical services are 3-4 sessions. The rationale for this is unclear. Regardless, with a lack of primary care services, it is unclear that it has any relation to integrated care except perhaps (1) trying to expand access, (2) offering brief interventions, and (3) getting referred by primary care. Importantly, an internet search suggests that the clinic is staffed by graduate psychology students, supervised by psychology faculty. It is unclear what role for psychopharmacology is present, and this would appear to be a major difference with many forms of IPC as the primary care physicians (and on some models psychiatric professionals) can offer psychopharmacological interventions. The parameters and criteria for the interventions are also not adequately detailed to assess their claims about efficacy/effectiveness in the conclusion. It would be helpful to know more about what criteria are used for discharge, completion, or referral out to higher levels of care. It would also be helpful to have a discussion comparing their criteria more fully to fidelity IPC models if the authors insist on this comparison.

2) It is unclear why these two objectives relate to each other in a meaningful way for a single paper. Epidemiological considerations during COVID and the "effectiveness and efficacy" of IPC (on which see below) are quite different topics. Neither objective has a robust additional data with which to explore the various explanations that the authors suggest may explain their findings. This may be understandable given limitations of their non-identifiable dataset, but it raises the sense that two different topics don't have any obvious relation. Moreover, there may be some secondary analyses that might be possible with their data. For instance, is there variation in severity of CAT-MH scores across time during COVID or do rates o presentation/referral/intake vary during COVID. It is not clear that the period between March 11, 2020 and June 2022 should be taken as one homogenous mental health period. These findings would be more informative in order to appropriately interpret their CAT-MH findings.

Given that the topics appear different and if additional exploratory analyses are not possible with whatever other data the authors may have on outcomes, the authors might consider dividing this into two briefer studies submitted as brief reports independently.

3) The exploratory components of the study appear to be preliminary assessments for implementation outcomes. A description of whether the 1-100 point scales had greater than two anchors would be helpful. There are a number of validated implementation scales. It is acceptable to use these 1-100 points scales without validated psychometrics rather than validated implementation scales with standardized psychometrics. However, further description of the anchors of these scales (or any comparison where the scales are used elsewhere) would help.

4) There conclusion that "the results demonstrate the effectiveness and efficacy of services modeled on IPC in reducing barriers to accessing mental health care" appears to be overstated for two reasons. (A) The fact that this is the model is unlike IPC as noted above. (B) The exploratory findings reflect an (early phase) implementation study. There is no clinical outcome with which to assess effectiveness or efficacy as standardly understood. Even if we allow leeway in noting that the authors are speaking of "efficacy ... in reducing barriers" some robust operationalization (and likely comparison) would be needed to "demonstrate ... efficacy." There are a variety of ways in which implementation might be measured and implementation outcomes can be compared across groups, but this doesn't appear to be considered.

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Reviewer #1: Yes: Rotem Rosenthal Oren

Reviewer #2: No

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PONE-D-23-00898R1Walk-in mental health: Bridging barriers in a pandemicPLOS ONE

Dear Dr. Wellspring,

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 Aug 24 2023 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,

Yaara Zisman-Ilani

Academic Editor

PLOS ONE

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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)

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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: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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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

Reviewer #2: No

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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: Yes

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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: I appreciate the authors' work in response to the comments. In particular, the elaboration of the pandemic's impact on mental health in the introduction and the explanations of the outcomes regarding depression and suicidality are now much more comprehensive. However, I still think the link between the two subjects (service satisfaction and mental health before and during COVID) is not strong and doesn't justify including them in the same paper. Below I provide some more specific comments.

Title and Abstract

1. The revisions made in the title and abstract highly improved these sections.

Introduction

2. In line 68, the word "however" should be removed because this sentence doesn't seem to contradict the previous sentence.

3. Lines 100-103 belong in the METHODS section, not the introduction.

4. I still don't understand why the authors describe the service as IPC. Since the service in the current study doesn't include physicians or any kind of multidisciplinary team, I don't see why it is considered IPC. Therefore, I think the paragraphs about IPC (lines 104-126) should be removed

5. Lines 119-125 seem irrelevant to the paper's topic.

6. I think there is still too much information about SST and IPC and the introduction is still highly unbalanced, with two and a half pages about SST/IPC and only one page about COVID-19. It is also confusing that the authors write about SST, IPC, walk-in clinic, and CC. The part about CC (line 109) can be removed from the introduction because it is described again in the PARTICIPANTS section.

7. The introduction of COVID-19 (line 127) is not well connected to the IPC paragraph that precedes it.

8. Personally, I think it would be better if Covid-19 is described first and SST is described afterward, with lines 149-151 serving as the bridge between these two subjects.

Objectives

9. It is unclear how lines 159-163 explain what follows them (the use of the CAT-MH).

Measures

10. Lines 192-196 belong in the CAT-MH paragraph (lines 218-257).

11. The CAT-MH section is a bit long. I suggest narrowing it down.

12. In line 280, "feedback forms are not dated" can be deleted because it is also written in line 293.

Discussion

13. Line 532, "The current study also found a higher rate of ‘positives’.." is missing "during the pandemic compared to before the pandemic".

14. In line 547, "The present study also illustrated that.." should be rephrased because this is not an additional finding but an explanation of the two findings described earlier.

15. The explanation in lines 559-566 is not clear enough. If you mean that clients had more time during the pandemic to seek treatment for their suicidal thoughts, then why only suicidal ideation was higher and not other symptoms as well?

Reviewer #2: The authors have improved the paper with regard to the concerns that both I and the other reviewer raised. However, I think that issues remain.

Major Concern:

1) Both reviewers were initially concerned that the manuscript was addressing to topics that were not obviously related. The authors revision has imporved this, but the rationale for the second objective given the first objective is still not as clear as it could be.

The authors state that the primary objective is exploratory analysis of qualitative feedback from clients about their experience of SST and their perceptions of its efficacy. To link this to the second objective, they write: "Further, it is acknowledged that situational and contextual factors are going to impact how services are accessed, as well as who accesses them. The role of client motivation may mean that those that sought the service may be those that were ‘ready’ for change. It is also acknowledged that those who were able to access the service were likely individuals who had privileges such as a stable internet connection and/or a working computer/tablet/cellphone. As such, a second objective of the present study was to utilize CAT-MH data to measure the nature and severity of mental health concerns of clients who accessed a walk-in mental health clinic before and during the COVID-166 19 pandemic." (Lines 159-166)

If I understand the authors correctly, this simply means something like "A secondardy objective was to contextualize the qualitative findings in regard to the nature and severity of clients' mental health concerns, as assessed by CAT-MH, because severity is known to correlate with length of time in treatment [or perhaps "time to remission" or perhaps both--here any number of citations could be given]." All the other suggestions appear speculation of potential explanations that are more appropriate in some other section (likely the discussion section). However, it's unclear if I understand them right. If I do not understand them right, the the specific claims need to be justified for the methods section.

Of particular note here, their discussion of "readiness for change" and other socioeconomic determinants does not appear to be measured by the CAT-MH. Thus, if those issues are part of the objective, the study cannot in principle achieve this objective.

2) While the author's revision as above gives more clarity to why two seemingly different topics are brought together into a single paper, I don't see that the authors actually "contextualize" anything in the discussion. The discussion is still offered as largely two independent topics. The secondary objective doesn't obviously contribute to contextualization of the first in the discussion. I think that if I am right about the way the authors are trying to relate the two issues, the discussion needs to reflect that this is a goal.

Significant Concerns to Consider Accounting For:

3) I believe the authors should consider whether they could conduct a secondary analysis for variation during the pre- and during-covid periods in (1) rate of appointments over smaller units of time and (2) severity of symptoms over smaller units of time. I understand they are conducting multiple tests and have already conducted a Bonferroni correction. While it is reasonable to set the parameters for initial analysis purposes, I believe that a secondary analysis would shed more light on the author's finding of the decreased rate of depression with concurrent the increased rate of suicidality that they saw during the Covid period. I take it the author's believe (rightly) that this is one of their most intriguing findings, but they could improve their speculations about it in the discussion through secondary analysis of how suicidality, depresison, and other CAT-MH symptomology varied over time.

Two points are important here:

(a) The authors overlook several possible explanations of the apparent paradoxical finding of decreased depression with increased suicidality that variation of symptoms in time would explain. For instance, high depression scores early in Covid during and shortly after lockdown orders could be masked by increased rate of presentation that they report during Covid on the whole. It is possible that most suicdality presented at time periods that coincide with higher depression scores, but that increased rate of presentation watered down the depression score for the Covid period on the whole. If that were the case, the paradox of increased suicidality rate with decreased depression scores would merely be an artifact of the author's approach. Relatedly, the authors note that they began to offer telehealth services during Covid. In my clinic (and those of my colleagues), the no show rate dropped significantly once telehealth was started. Anecdotally, that easier access seemed to have coincided with more individuals with less symptom burden presenting--even though some individuals got much sicker. (My understanding is that others observed the same phenomneon). Likewise, public attention to mental health during the covid period grew vastly, which might also have resulted in a greater presentation rate of individuals that would not otherwise have presented.

(b) In response to my earlier suggestion they merely stated: "we believe that from a mental health perspective, it is reasonable to consider this as a homogenous group in the present study, due to the salience of mask mandates, physical distancing, etc., that were present throughout this time" in light of the fact that "there has been minimal societal change, COVID-19 is still considered a pandemic, etc." First, this hypothesis is testable by the secondary analysis above. Second, it is not clear that societal change was minimal during this time: there were multiple variations in infection rate, death rate, and hospitalization rate during these periods. There was also significant variation (at least in some locations that I'm more familiar with than the author's location) between stay at home order intensity, amount of standard public interaction, and whether or not children/parents could engage in normal school/work/recrational activities.

Minor comments:

4) Single Session Therapy is mentioned at line 77, but the acronym SST is not introduced to the next mention of SST @ line 78. The acronym should be placed after the first mention.

5) The full name, Computerized Adaptive Testing - Mental Health, is used in the abstract, then CAT-MH is used in several parts of the main paper as an acronym before the full name is respicified at line 221. Please spell out the full name at first use.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-23-00898R2Walk-in mental health: Bridging barriers in a pandemicPLOS ONE

Dear Dr. Wellspring,

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.

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I agree with the reviewers' judgments recommending minor revisions. Please attend to the minor revisions noted by the reviewers, and also, please include the period of time from which client data were used in the method section--this was included later in the manuscript but should also be included in the method section, as it highly relevant to contextualizing the data.

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

Please submit your revised manuscript by May 17 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.

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We look forward to receiving your revised manuscript.

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Emily Lund

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:

I agree with the reviewers' judgments recommending minor revisions. Please attend to the minor revisions noted by the reviewers, and also, please include the period of time from which client data were used in the method section--this was included later in the manuscript but should also be included in the method section, as it highly relevant to contextualizing the data.

[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: 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: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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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

Reviewer #2: No

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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: Yes

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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: I appreciate the authors work on the manuscript, which is now more integrative.

Below are some minor issues I suggest to address.

Introduction

• The revisions made in this section are excellent.

Methods

• Line 171 “However, the number of sessions was 172 altered if extenuating circumstances were present (e.g., suicidal ideation or other forms of 173 imminent risk).” - Are there participants in the current study that attended more than 4 sessions due to such circumstances? If so it should be considered whether they should have been removed from analysis because it becomes a different kind of treatment and not necessarily SST.

Discussion

• Lines 469-473: Does this sentence reflect in the results as well? Did participants address this advantage in the open ended questions?

• Lines 536-538: I suggest to remove this because it’s not directly related to the current study.

• Line 606: IPC was removed from the paper so it should be removed from here also.

Reviewer #2: The authors have improved the manuscript significantly. I have only minor, easily addressable comments below.

Substantive comments:

1) P. 33, line 559 says that a hypothesis about increased suicidality resulting from improved ease of access was "substantiated" by the qualitative findings which reflect ease of access. However, the anonymity of the authors' data precludes showing that the individuals with suicidality were the ones who reported increased ease of access. Thus, the verb should be weakened to one that doesn't suggest direct hypothesis testing occurred. "Supported" would be one alternative.

2) P. 35, line 606: The paper is no longer discussing IPC and hence reference to IPC needs to be replaced here.

Minor grammatical comments:

1) P. 13, lines 83-84: "the Covid-19" is awkward. Perhaps either the "the" should be deleted or "pandemic" (or some similar word) should be added.

2) P. 14, line 99: consider hyphenating "anxiety-related disorders."

3) P. 14, lines 101-103: "A notable symptom related to depression (and is comorbid with other related diagnoses) is the..." is not parallel. Considering the phrase after the "and" renders the predicate to read "symptom ... is ... is." Perhaps the "and" is supposed to be a "that."

Additionally, this sentence mistakenly reads that "a ... symptom ... is the rates," which is non-sensical/a category mistake. The authors appear to be meaning to talk about the rates of symptoms rather than saying that the symptom(s) is/are themselves rates.

4) P. 14, lines 114-115: "including, and Single Session Therapy" is ungrammatical. Either the "and" should be deleted or another noun is needed before it.

5) P. 15, line 129: A space is needed after "visit."

6) P. 17, lines 183-184: The phrase "despite an absence of co-located care" is now unnecessary because the prior framing of the paper in terms of integrative care has been changed. In that setting, it is also confusing. Consider deleting.

7) P. 32, line 539: The first sentence of the paragraph is ungrammatical with subject predicate disagreement between "is" and "results."

8) P. 32, line 541: There is a comma splice after "WWIC."

9) P. 35, line 626 et passim: The beginning of the sentence is wordy and awkward: "A specific recommendation that may arise from these findings is for programs and service providers to ..." Consider reducing wordiness.

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Reviewer #1: No

Reviewer #2: No

**********

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Walk-in mental health: Bridging barriers in a pandemic

PONE-D-23-00898R3

Dear Dr. Wellspring,

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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Kind regards,

Emily Lund

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: