Anxiety and depression among hypertensive patients during the COVID-19 pandemic: A cross-sectional study from Kathmandu Metropolitan, Nepal

Dilasha K. C.; Hari Prasad Kaphle; Durga Shrestha; Nirmala Neupane

doi:10.1371/journal.pone.0308048

Peer Review History

Original SubmissionAugust 18, 2023
12 Apr 2024 Decision Letter - Aysha Almas, Editor PONE-D-23-25764Anxiety and Depression among Hypertensive Patients during the COVID-19 Pandemic: A Cross-Sectional Study from Kathmandu MetropolitanPLOS ONE Dear Dr. Shrestha, 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. It is an interesting study from LMIC during covid pandemic and address important illness of depression Please submit your revised manuscript by May 27 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. 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Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 4. We are unable to open your Supporting Information file [S1 file.sav]. Please kindly revise as necessary and re-upload. Academic Editor comments: Please address the following comments from reviewers Review 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. 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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: No Reviewer #3: No ****** 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: The authors present findings from their cross-sectional study regarding anxiety and depression in hypertensive patients in Kathmandu during the COVID-19 pandemic. I am not clear on what new knowledge findings of this study add to the available evidence. The introduction section states hypertension as a problem, however, doesn't apprise the reader of anxiety/depression prevalence in the study setting. The inclusion criteria was based on including patients with hypertension only, however given the rise of multimorbidity in low and middle income countries, this is not representative of the general population. Contrary to what authors state in the manuscript about the findings being representative of the people with hypertension, however this may not be the case because of the inclusion/exclusion criteria and use of a convenience sampling technique. Why did the authors decide to use bivariate logistic regression analysis and not multivariate? Authors mention as part of limitations that data regarding pre-existing diagnosis of anxiety and/or depression was collected, however this is information would have presented a close approximation of the magnitude of association of COVID-19 pandemic with anxiety and/or depression in this population. Reviewer #2: Overall The authors have discussed an important aspect of health in hypertensive patients: Mental well being. The authors however need to make some changes in the manuscript prior to its acceptance. Moreover, there are grammatical mistakes, and some sentences do not make sense due to absence of a comma or semicolon. One example is given below "The WHO reports that the increase in mental health problems like depression and suicide is on the rise globally [4], in the light of this pandemic." Instead of 'is' it should be are Introduction 1. Covid-19 has changed a lot in the past two years. The figures cited in the initial paragraph are from 2020 and do not give a true picture of what is happening currently. 2. The authors write "It is also noted that in the case of Nepal, vulnerable groups, especially chronic disease patients are susceptible to infection and deaths due to COVID19". This is true globally and not just for Nepal 3. The authors have no cited any similar studies or any studies related to prevalence of hypertension or depression in Introduction. The authors fail to convince as to why they have chosen hypertensive patients. As per WHO "Nearly 1 in 4 people in Nepal suffer from hypertension, and less than 5% of hypertension patients have the condition under control" These type of figures should be quoted. In addition studies on Anxiety and Depression among Hypertensive Adults in Nepal should be cited and rationale be made regarding covid-19 Methodology 1. Cite the STEPS survey 2. Why only 40-59….are we only looking at middle-aged adults 3. Good validation, reliability and pretesting 4. No definition of ethnicity in methodology Results 1. Self-owned business – better word instead of own business 2. Was moderate level physical activity self reported or calculated using a IPAQ questionnaire 3. Too many tables. Table 2 and 3 can be supplementary 4. Table 7 could be better if Models were created Discussion 5. Better to have a complete summary of results in 1st paragraph 6. Typically people who smoke tend not to be worried about their health risks due to smoking. There is also lack of reference citation 7. Explanations for risk factors behind anxiety are much or less the same. They can be grouped together rather than writing again. 8. Rather than stating different periods as the reason behind differences in finding, the study in Ethiopia didn’t look at covid-19 pandemic 9. Any strengths that can be included in the discussion Conclusion 10. Rather than stating anxiety and depression, it would be better to state that the risk factors had an association with "symptoms" of anxiety and depression Reviewer #3: minor grammatical errors are present during the writing of this manuscript especially in the introduction and discussion section. The discussion section must be made more robust. Other comments have been highlighted with comments. ****** 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: Saad Bin Zafar Mahmood Reviewer #3: Yes: Zeerak Jarrar ******** [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". 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Revision 1
25 Jun 2024 Author Response Journal requirements 1- When submitting your revision, we need you to address these additional requirements. 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. Response: Thank you for your valuable feedback. We appreciate your feedback. We have provided our best efforts to meet the journal requirements. 2-Did you know that depositing data in a repository is associated with up to a 25% citation advantage (https://doi.org/10.1371/journal.pone.0230416)? If you’ve not already done so, consider depositing your raw data in a repository to ensure your work is read, appreciated and cited by the largest possible audience. You’ll also earn an Accessible Data icon on your published paper if you deposit your data in any participating repository (https://plos.org/open-science/open-data/#accessible-data). Response: Thank you for your feedback and the valuable information. 3- Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Response: Thank you for your feedback. We have removed the data from Supporting file as it was not able to open and have deposited in an appropriate public repository as suggested. 4- We are unable to open your Supporting Information file [S1 file.sav]. Please kindly revise as necessary and re-upload. Response: Thank you for your valuable comment. We have revised and re-uploaded it again for your kind perusal. We have deposited in an appropriate public repository. The published data can be accessed through the URL: https://www.openicpsr.org/openicpsr/project/206621/version/V1/view and it’s DOI is https://doi.org/10.3886/E206621V1 Reviewer #1 A) The authors present findings from their cross-sectional study regarding anxiety and depression in hypertensive patients in Kathmandu during the COVID-19 pandemic. I am not clear on what new knowledge findings of this study add to the available evidence. The introduction section states hypertension as a problem, however, doesn't apprise the reader of anxiety/depression prevalence in the study setting. Response: This study adds valuable data on the prevalence and risk factors of anxiety and depression in hypertensive patients in a specific low-income setting like Nepal during the COVID-19 pandemic. This is crucial for developing tailored interventions and coping strategies that are culturally and socio-economically appropriate in local context. In addition, the study underscores the need for early intervention and the development of coping strategies to mitigate the mental health impacts of the pandemic. This can inform public health policies and healthcare practices in similar low-income settings, emphasizing the importance of mental health support alongside physical health management for hypertensive patients. Thank you for your comment. Now, we have acknowledged it, further corrected the introduction and focused on the cause of this study. Please see pages 3 and 4 in the revised manuscript. B) The inclusion criteria was based on including patients with hypertension only, however given the rise of multimorbidity in low and middle income countries, this is not representative of the general population. Contrary to what authors state in the manuscript about the findings being representative of the people with hypertension, however this may not be the case because of the inclusion/exclusion criteria and use of a convenience sampling technique. Response: We accept your valuable comment. Due to resource constraints, and as a practical option we particularly focused on hypertension in Nepal in our study. Now we have acknowledged it in our study limitations. Please see page no 22 and 23 in the revised manuscript. C) Why did the authors decide to use bivariate logistic regression analysis and not multivariate? Response: Thank you for your query. The bivariate logistic regression was used due to the limited sample size. Moreover, this cross-sectional study is a preliminary step before conducting subsequent studies followed by multivariate logistic regression analysis. D) Authors mention as part of limitations that data regarding a pre-existing diagnosis of anxiety and/or depression was collected, however this is information would have presented a close approximation of the magnitude of association of COVID-19 pandemic with anxiety and/or depression in this population. Response: Thank you for your valuable comment. As a researcher, we have tried our best to incorporate information on anxiety and depression. However, we acknowledge the limitations of an absence of pre-existing data on anxiety and depression, mostly due to resource constraints in reaching pre-diagnosed patients in the pandemic, and have further elaborated on it in our study limitations. Please see page no. 22 and 23 in the revised manuscript. Reviwer#2 A) The authors have discussed an important aspect of health in hypertensive patients: Mental well being. The authors however need to make some changes in the manuscript prior to its acceptance. Moreover, there are grammatical mistakes, and some sentences do not make sense due to absence of a comma or semicolon. One example is given below "The WHO reports that the increase in mental health problems like depression and suicide is on the rise globally [4], in the light of this pandemic." Instead of 'is' it should be are Response: Thank you for your valuable comment. Now it has been thoroughly revised and addressed in the revised manuscript. Please see page no. 3 and 4 in the revised manuscript. B) Introduction 1. Covid-19 has changed a lot in the past two years. The figures cited in the initial paragraph are from 2020 and do not give a true picture of what is happening currently. Response: Thank you for your valuable comment. We have further solidified the evidence related to COVID-19. We have removed the old figures from 2020 in the revised manuscript. Please see page no 3 and 4 in the revised manuscript. 2. The authors write "It is also noted that in the case of Nepal, vulnerable groups, especially chronic disease patients are susceptible to infection and deaths due to COVID19". This is true globally and not just for Nepal Response: We acknowledge your valuable comments. Now it is addressed. Please see page no 3 in the revised manuscript. 3. The authors have no cited any similar studies or any studies related to prevalence of hypertension or depression in Introduction. The authors fail to convince as to why they have chosen hypertensive patients. As per WHO "Nearly 1 in 4 people in Nepal suffer from hypertension, and less than 5% of hypertension patients have the condition under control" These type of figures should be quoted. In addition studies on Anxiety and Depression among Hypertensive Adults in Nepal should be cited and rationale be made regarding covid-19 Response: We accept your comment. It has been addressed in the revised manuscript and rationale has been added to strengthen the point of this study. Please refer to page no. 3, 4 and 5 in the revised manuscript. C) Methodology 1. Cite the STEPS survey Response: Now we have added the citation and reference for the sentences. Please see page no 4 in the revised manuscript. 2. Why only 40-59….are we only looking at middle-aged adults Response: Thank you for your insightful comment. It has been addressed in the revised manuscript and rationale has been added to strengthen the point of this study. Please refer to page no. 5 in the revised manuscript. 3. Good validation, reliability and pretesting Response: Thank you for your valuable comment. 4. No definition of ethnicity in methodology Response: Thank you for your valuable comment. Now it is addressed. Please see page no 7 in the revised manuscript. D) Results 1. Self-owned business – better word instead of own business Response: Thank you for your valuable suggestion. Now it is addressed. Please see page no 9 and 10 in the revised manuscript. 2. Was moderate level physical activity self-reported or calculated using a IPAQ questionnaire Response: We acknowledge your comment. The moderate level of physical activity was self-reported by the respondents in this study. 3. Too many tables. Table 2 and 3 can be supplementary Response: Thank you for your valuable comment. However, we think Table 2 is significant as it provides the prevalence rates of anxiety and depression among hypertensive patients during the COVID-19 pandemic in Kathmandu Metropolitan, Nepal. It is crucial because it quantifies the extent of mental health issues among the study population, which is essential for understanding the impact of the pandemic on this group. The data can inform healthcare providers and policymakers about the need for targeted mental health interventions. Similarly, Table 3 presents the association of sociodemographic characteristics with anxiety and depression among hypertensive patients during the COVID-19 pandemic which is one of the main objective of this study so, although it is long but we believe it is reasonable. 4. Table 7 could be better if Models were created Response: We acknowledge your valuable feedback. Unfortunately, due to limited sample size we are currently unable to generate these models. E) Discussion 5. Better to have a complete summary of results in 1st paragraph Response: Thank you for your valuable comment. Now, we have acknowledged it. Please see page no. 20 in the revised manuscript. 6. Typically people who smoke tend not to be worried about their health risks due to smoking. There is also lack of reference citation Response: Thank you for your valuable comment. We have removed the statement. 7. Explanations for risk factors behind anxiety are much or less the same. They can be grouped together rather than writing again. Response: Thank you for your valuable comment. We have acknowledged and revised it. Please visit page no. 19, 20, 21, 22 in the revised manuscript. 8. Rather than stating different periods as the reason behind differences in finding, the study in Ethiopia didn’t look at covid-19 pandemic Response: Thank you for your insightful comment. We have acknowledged and revised it. Please visit page no. 20, 21 in the revised manuscript. 9. Any strengths that can be included in the discussion Response: Thank you for your valuable comment. We have acknowledged and revised it. Please visit page no. 22 in the revised manuscript. F) Conclusion 10. Rather than stating anxiety and depression, it would be better to state that the risk factors had an association with "symptoms" of anxiety and depression. Response: Thank you for your valuable comment. We have acknowledged and revised it. Please visit page no. 23 in the revised manuscript. Reviewer#3 A) minor grammatical errors are present during the writing of this manuscript especially in the introduction and discussion section. The discussion section must be made more robust. Other comments have been highlighted with comments. Response: Thank you for your valuable comment. The correction for grammatical errors has been addressed in the introduction and discussion sections and other highlighted comments have also been addressed. https://doi.org/10.1371/journal.pone.0308048.r002
17 Jul 2024 Decision Letter - Aysha Almas, Editor Anxiety and depression among hypertensive patients during the COVID-19 pandemic: A cross-sectional study from Kathmandu Metropolitan, Nepal PONE-D-23-25764R1 Dear Dr. Shrestha 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, Aysha Almas, MBBS, FCPS, MSc Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0308048.r003
Formally Accepted
22 Jul 2024 Acceptance Letter - Aysha Almas, Editor PONE-D-23-25764R1 PLOS ONE Dear Dr. Shrestha, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Aysha Almas Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0308048.r004

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