PONE-D-24-04624Generalized anxiety disorder among patients with chronic pain in MalaysiaPLOS ONE

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PLOS ONE

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Reviewer #1: Partly

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: 1. Title: the title might be misleading. It should be the “prevalence and factors associated with Generalized anxiety disorder among patients with chronic pain: a single center cross sectional study in Malaysia”

2. Abstract

a. Introduction: OK

b. Method: better to mention what type of analysis used to determine factors associated with GAD

c. The phrases “Multiple logistic regression showed the existence of chronic pain amongst GAD patients,…” this phrase is quite confusing. This study population is among the chronic pain patients or GAD patients? no need to mention this as it is confusing. Just mention what are the associated factors associate with GAD

d. Conclusion: “Chronic pain was a prevalent condition in GAD patients”. I think the more accurate phrase is “GAD is a prevalent condition among chronic pain patients”.

3. Introduction

a. There is no problem statement mentioned in the introduction. Please state what are the challenges or issues that need to be addressed in regards to GAD in chronic pain patients. in addition, the author needs to mention why it is important to do this study and its significance.

b. There is no statement regarding what the current knowledge on the factors is associated with GAD among chronic pain patients. I believe there are previous studies that explore this issue. For example, a narrative review by Lokapur et al., (2023) revealed that a total of 84 articles were included in the analysis of depressive and/or anxiety disorders with chronic pain conditions in the Indian populations (DOI: 10.4103/ijpn.ijpn_26_21)

c. If there is various studies that are explored regarding factor associated with GAD in chronic pain patients, what are the new knowledge that could be obtained from this study?

4. Method

a. Regarding study population, is there any reason on why only one hospital is selected for the study population? This is because in the title the author specifically mentioned “ Generalized anxiety disorder among patients with chronic pain in Malaysia” whereby I believe there is more than one hospital with pain clinic in Malaysia.

b. Sample size calculations, please mention what are the formula used (rather than mentioning about the tool used, please be specific), the prevalence of GAD among patients in rheumatology clinic, what are the confidence intervals and desired precision. I believe the sample size the author acquire is too low and not adequate to detect the desired prevalence of GAD in the study population.

c. Please describe how the study population are diagnosed with chronic pain. For how long did they suffer from the pain before they are diagnosed? How about pain clinic patients that were admitted? Do they included in this study?

d. Regarding study location, please describe about it, the population demography etc.

5. Results

a. Regarding descriptive analysis, please state the distribution of continuous variable (age) whether it is normal distributed or not

b. The statement “The prevalence of GAD: By means of M.I.N.I, 38 participants were diagnosed with GAD (18.9%). Hence, the prevalence of GAD in our population was 18.9%”, (it is better to avoid repetition)

c. It is interesting if the author included the univariate analysis results in the article. Authors can include the univariate analysis separately or in the same table as the multivariate analysis table.

d. Similarly, it is interesting if the author can include in the multivariate analysis table, the comparison of have GAD/no GAD for all the variables analyzed. This information is valuable for the readers to make sense of the data that the authors concluded.

e. Univariate analysis also is important to look for which variables that the authors included in the multivariate analysis. As far as my understanding, the authors only included the three variables in the multivariate analysis which are duration of pain, gender, and pain severity. The authors might miss other important variables to include in the multivariate analysis, such as education level, income status, and employment status, due to the use of p<0.05 as cut off points. According to Hesmer and Lemeshaw, the use of traditional levels such as 0.05 often fails to identify variables known to be important (Bursac et al. 2008).

6. Discussion

a. I believe that the study population is likely to be lower than is should be. By evidence of wide confidence interval for the association of gender (AOR:7.94; 95% CI:2.34, 26.93) and pain severity (AOR:18.75; CI:1.23,285.13) with GAD. Avijit Hazra (2017) stated that a wide confidence interval (CI) can indicate that the sample size is small thus producing less precise results. Please add in the limitation on why the study population is lower (if the author think otherwise/sample size is actually adequate, please justify it with reference)

b. For every significant and non-significant finding, please state what are the significance and please provide recommendations for policy maker, clinicians, public health practitioner, and future study.

c. I believe there is a lot to discuss about the study findings. Please discuss on why the other important variable (marital, education, employment, income, diagnosis, and type of analgesic) is not significantly associated with GAD.

7. Conclusion

a. In the conclusion, it is better to conclude the findings according to your study objectives.

8. References

a. Some references in the text are not consistent. The is a mix of usage of Vancouver and APA reference style. For example, in the discussion section, third paragraphs, “This finding was compatible with a population base study investigating differences in pain severity for arthritis, migraine, and back pain in which high pain scores were reported among patients with GAD compared to patients with pain alone (Csupak et al., 2018). Moreover, Jun et al. [21] established that high pain scores as well as increased level of anxiety were linked to elevated pain catastrophizing.” Please refer to the journal’s standard.

b. please refer journal's standard

Reviewer #2: Dear Authors,

Thank you for submitting your manuscript to the journal. Your study on the prevalence of Generalized Anxiety Disorder (GAD) among patients with chronic pain in Malaysia provides valuable insights into a critically under-researched area. The study design, methodology, and statistical analyses appear robust and well-executed. The ethical considerations are appropriately addressed, and the conclusions drawn from the analyses are supported by the data. However, I would like to raise a concern regarding the availability of the data supporting your findings. Ensuring that data are freely available enhances transparency, allows for the verification of results, and supports the reproducibility of the study.In conclusion, with adjustments to the data availability statements and minor enhancements in the reporting of your methods and results, your manuscript would be a significant contribution to the literature. I look forward to your revisions and potentially the broader dissemination of your findings.

Best regards

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Reviewer #1: Yes: MOHD FAZELI SAZALI

Reviewer #2: No

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Prevalence and factors associated with Generalized anxiety disorder among patients with chronic pain: A single center cross sectional study in Malaysia

PONE-D-24-04624R1

Dear Dr. Ariaratnam,

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Kind regards,

Syed Sharizman Syed Abdul Rahim, MBBch BAO, MPH, DrPH

Academic Editor

PLOS ONE

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