PONE-D-23-30089The prevalence and predictors of mental health and addiction concerns during the COVID-19 pandemic in Ontario, Canada: A cross-sectional studyPLOS ONE

Dear Dr. Markoulakis,

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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Guillermo Salinas-Escudero, PhD. MsC.

Academic Editor

PLOS ONE

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This work was supported by the Canadian Institutes of Health Research (AL, SK, RM; grant number UIP-178831) and the Hurvitz Brain Sciences Summer Student Research Program (OC) through the Sunnybrook Research Institute. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. 

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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: No

Reviewer #2: Partly

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

Reviewer #1: No

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: Yes

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: It is necessary adequately define the objective of the study, what specific result you want to present and redo the analysis in that sense. What does this article contribute to?

Introduction:

It covers many topics without delving into any of them, prevalence, predictors, disparities…. It is not clear what he calls “mental health concerns”.

Methodology

It is not described, everything refers to another document, it is not possible for the reader to understand the basic source of information or methodology with what is provided in the section.

1) It seems to me that there was no reflection on the results to be presented, there is no robust conceptual or theoretical presentation. It is not defined what they call MHA or pandemic related outcomes.

2) how they model the socioeconomic condition, to adequately isolate the symptoms from what is attributable to the experience with the COVID pandemic.

Omissions with potentially serious biases in the prevalence measurement:

• They do not include if people already had a diagnosis and/or received treatment for the mental health condition, then, prevalence of what the survey measures? people with symptoms and not treated, or treated inappropriately?

• It is not described what they include as variables associated with covid, the person or close family member had COVID, was they hospitalized or even died from this cause?, whether they have already received the vaccine or not.

• The presence of symptoms of depression and anxiety represents 35.7% of the study population, and authors omits to analyze this population!!

- Using the word predictors is wrong as it comes from a cross-sectional survey

2) Why ruin all the work of collecting a large sample by dividing the statistical analysis of the sample into two parts. Why a separate regression model for anxiety and another for depression, what justification does this strategy have, and again why does it not model the depression-anxiety comorbidity?

3) The regression models seem poorly worked to me, examples:

• What was the point of seeing in Table 1 that there are differentiated patterns by age, if the multivariate model includes the age variable as a linear continuous, without any type of adjustment.

• What the variables Fear of covid, unmet MHA service needs mean.

Results

Table 1: It is necessary to reflect on what is presented

- How useful are the columns (not depression and not anxiety)?

- Why population with anxiety and depression symptoms are no presented?

- I think these columns should be contrast: Total population, Pop with symptoms of depression, Pop with symptoms of anxiety, Pop with symptoms of both, and Pop without symptoms

Table 2: I do not understand this table,

- Why not present levels or severity of symptoms instead of presenting averages.

- How useful is it to compare the average response of the non-depressed population with depression, if the measuring instrument to classify in column as in row was the same

Table 3 and 4

It seems absurd to me to divide the analysis into two models, the study variable is mental health at the population level. It is necessary to reflect on how to properly model

Reviewer #2: The study reports findings on mental health and addiction concerns on adults in Ontario, Canada. This issue is important globally due to its possible increase during and after the COVID-19 pandemic.

The study design is cross-sectional and the attribution of causality with the pandemic has important limitations inherent to the data. Therefore, it is important that the authors point out more clearly that the increase in the occurrence of mental health and addiction concerns may be due to the pandemic or due to greater visibility of mental health issues (better and greater diagnostic coverage).

From a methodological point of view, the statistical analysis did not take advantage of the possibility of exploring contextual effects that seem to have had an impact on the findings. See table 1 for the differences between Southwestern Ontario, Eastern Ontario and Central Ontario. It would be interesting to know the results of a multilevel analysis, since the findings on the protective association of social support are suggestive of differential social processes between the regions.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-23-30089R1The prevalence of mental health and addiction concerns and factors associated with depression and anxiety during the COVID-19 pandemic in Ontario, Canada: A cross-sectional studyPLOS ONE

Dear Dr. Markoulakis,

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.

==============================I agree with the opinion of both reviewers. The authors should have delved into the answers to the questions made by the reviewers. Therefore, the next version needs to include the required changes and adequately support the content of the work; otherwise, I suggest rejecting the work for publication.

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

Please submit your revised manuscript by Mar 15 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,

Guillermo Salinas-Escudero, PhD. MsC.

Academic Editor

PLOS ONE

Additional Editor Comments:

I agree with the opinion of both reviewers. The authors should have delved into the answers to the questions made by the reviewers. Therefore, the next version needs to include the required changes and adequately support the content of the work; otherwise, I suggest rejecting the work for publication.

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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: All comments have been addressed

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: Partly

Reviewer #2: Partly

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

Reviewer #1: No

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: Yes

Reviewer #2: Yes

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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: Although the authors responded to each observation, substantial aspects were left unaddressed.

The study could provide information on the prevalence of depression and anxiety symptoms, 2 years after the appearance of COVID-19 and contact restrictions. However, with the information added by the authors, in this second review I doubt whether the study is representative of the target population, since they mentioned that it is a non-random sample.

The methodological description of population selection remains incomplete. Crucial aspects to understand how the sample was selected were omitted. In the response they showed that the sampling was a non-random sampling by quotas, this aspect totally changes the external validity of the study, and it would be necessary for the authors to show simple evidence of the representativeness of the sample, in the same document, and not just reference other documents.

Another aspect about the selection is that they report that they were participants registered in “Delvinia’s AskingCanadians responder”, without explaining in the slightest or making any reference to it.

Another important aspect is that, given the observation that the analysis "independently" analyzes the population with two of the health conditions, the authors only respond "because it is of interest to them." However, they do not support this assumption of independence on background, nor do they do any statistical treatment to show what they are talking about. I find it questionable that they show blindness to a large proportion of the population who report both health conditions.

Regarding the statistical analysis, the observation was made that there are differentiated effects by age groups, but in the regression analysis the authors only included the continuous variable, and it is not mentioned that non-linearities were evaluated. And the authors only responded that there were already many categorical variables.

Due to the above, I think that the article only provides information on prevalence, since the association analysis is still very incipient.

Reviewer #2: The new version included many recommendations from reviewers and is better than the previous one. However, it has an inconsistency between the introduction and analysis of the data. In the introduction it is indicated that the context can be a determinant of outcomes, but it is not explored. Only individual data is analyzed. The authors' explanation for not doing multilevel analysis is insufficient. It is suggested that the authors point out as a limitation that only individual variables and not contextual variables were explored, which can lead to a psychological fallacy (see Diez-Roux AV. Bringing context back into epidemiology: variables and fallacies in multilevel analysis. Am J Public Health 1988;88(2):216-22.

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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: No

Reviewer #2: No

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[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.

The prevalence of mental health and addiction concerns and factors associated with depression and anxiety during the COVID-19 pandemic in Ontario, Canada: A cross-sectional study

PONE-D-23-30089R2

Dear Dr. Markoulakis,

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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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,

Guillermo Salinas-Escudero, PhD. MsC.

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

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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

**********

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

Reviewer #1: 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

**********

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

**********

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 consider that the authors achieved a robust and interesting document ready to publish.

They carefully attended to the reviewers' observations and substantially improved the report.

The transparency of the document, the statistical analysis is more robust and the writing and discussion of results is more in-depth.

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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: Castro-Ríos A

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