PONE-D-24-07744Self-stigmatization and treatment preferences: Measuring the impact of treatment labels on choices for depression medicationsPLOS ONE

Dear Dr. Gonzalez Sepulveda,

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: Please review edits as recommended by the reviewer and respond to your comments. Depending on your responses the paper will be further reviewed for acceptance. 

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Please submit your revised manuscript by May 13 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.

Kind regards,

Souparno Mitra, M.D.

Academic Editor

PLOS ONE

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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: Yes

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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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 very practical and well thought out manuscript. All parts of the manuscript are easily understood and supported by the statistical and clinically relevant design. Table and figures are simple to comprehend.

Reviewer #2: Dear Editor,

I have had the honor of reviewing the article titled “Self-stigmatization and treatment preferences: Measuring the impact of treatment labels on choices for depression medications” submitted to PLOS One for peer review.

Below is the review:

Under Introduction:

“it is unknown whether self-stigmatization is exacerbated by association with conditions no experienced by the patients” Recommend reconstructing the sentence for clarity: Like “it remains uncertain whether associations with conditions not directly experienced by the patients exacerbate self-stigmatization.”

Under Methods:

“To avoid inducing a reaction from participants in response to these two attributes beyond what would be triggered by the product label” Recommend reconstructing the sentence for clarity: Like “To prevent eliciting a reaction from participants beyond those typically triggered by the product label”

Recommend only using attributes or characteristics and not interchanging them.

Define: akathisia and acronyms: SAS

Recommend using voluntarily instead of spontaneously and taking out the extra they in “Importantly, interview participants spontaneously shared concerns about the use of antipsychotics and a treatment indication for schizophrenia as they felt taking such medications would suggest their condition was severe”

In “The interviews were conducted individually through videoconferencing and followed a

semi-structured think-aloud protocol” Please describe how a semi-structured think-aloud protocol was followed.

“We accomplished the latter by running a 3-class model, where preferences in class 1 were required to favor treatments without an indication for schizophrenia (i.e., constraining the marginal effect of avoiding schizophrenia to be positive), preferences in class 2 were required to favor treatments with an indication for schizophrenia (i.e., constraining the marginal effect of treating MDD and schizophrenia to be positive). Preference estimates in class 3 were obtained without any parameter constraints.” Combine the sentences with a “while”.

Recommend making this a table for clarity as they are referenced frequently under results. In general, the statistical analysis was difficult to follow and understand. Recommend using more description and rewording sentences.

Under Results:

The first paragraph describing the number of participants and description of encounters can go in under

methods.

Use another phrase for “preference weights” or define what is being referenced by preference weights.

Reword for clarity: “We also noted a small, marginally statistically significant positive effect of additional context information on the acceptance of atypical antipsychotics and greater chance of indifference about the treatment indications.”

Under Discussion:

This sentence is not necessary: “While the effect is relatively small, we found evidence that it is likely pervasive”

Under “limitations” section: Other limitations identified are including and limited to not addressing other communication strategies, qualitative information on avoidance of adjuvant antipsychotics because of self-stigmatization was not taken from the participants who completed the online survey, and participants answered on the online survey may not reflect in their real-world decision making.

A suggestion to include is giving specific points that doctors can talk about to their patients that subside the patient’s aversion to adjuvant antipsychotics for MDD symptoms. Consider taking about directions for future research.

Limitations accounted for: consistency check was done where only data of good quality was taken into account and statistical lengths were taken to account for different variances in data.

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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.

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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: Rajesh Mehta

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.

PONE-D-24-07744R1Self-stigmatization and treatment preferences: Measuring the impact of treatment labels on choices for depression medicationsPLOS ONE

Dear Dr. Gonzalez Sepulveda,

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.

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

ACADEMIC EDITOR: Please see review comments including the ones alluding to including inclusion and exclusion criteria and resubmit for further consideration

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

Please submit your revised manuscript by Aug 03 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,

Souparno Mitra, M.D.

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 #2: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: 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 #2: Yes

Reviewer #3: Partly

Reviewer #4: Yes

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

Reviewer #2: Yes

Reviewer #3: I Don't Know

Reviewer #4: 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 #2: Yes

Reviewer #3: No

Reviewer #4: 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 #2: Yes

Reviewer #3: Yes

Reviewer #4: 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 #2: Thank you for the opportunity to rereview "Self-stigmatization and treatment preferences: Measuring the impact of treatment labels on choices for depression medications". All the requested review comments were adequately addressed.

Reviewer #3: Self-stigmatization and treatment preferences: Measuring the impact of treatment labels on choices for depression medications.

Summary of research

The paper by et al. analyzed the influence of medication product inserts on patients’ perception and their preference between treatment options. 501 Patients with MDD were made to complete DCE survey. Based on the result author suggest, Product-label treatment indication can potentially lead to patient self-stigmatization as shown by patients’ avoidance of treatments that are also used to treat schizophrenia.

Weaknesses:

1) In the study participants were made to read the label and make recommendations. It is important to consider the percentage of patients who read the labels of the medications in detail in real life scenario.

2) Psychoeducation plays a key role in preventing stigma in most patients with MDD. It is usual practice for psychiatrists to explain the risks, benefits, FDA black box warning, other indications of medications prescribed. Psychiatrists usually explain these to the patient before starting new meds and make them understand why specific medication was chosen for them and how it could help them. These discussions usually help in preventing stigma in most cases. I am curious to know in the study sample if a provider explained them the above and answered all questions.

3) Study states following: The additional information was intended to provide more context around the use of atypical antipsychotics to treat MDD mimicking the kind of information a patient could receive from physicians to alleviate problems with self-stigmatization. Respondents who were offered the additional information (context arm) were reminded explicitly that patients need not experience psychoses to benefit from antipsychotics.

---- It is important to note: The therapeutic alliance made between patients and psychiatrist usually makes a great difference in stigma, as patients trust on provider is greater to a researcher explaining them.

4) In discussion it states: Also, to some degree, our DCE question design included more information than the limited details given on product inserts to generate meaningful preference weights.

� It is important to know what additional information was added as it changes the validity of the study, and its application to real life scenarios.

Major issues:

1) Inclusion criteria: Specification regarding inclusion criteria is missing. Recommended to write clear inclusion criteria.

Pl refer to PLOS ONE submission guideline: https://journals.plos.org/plosone/s/submission-guidelines#:~:text=In%20the%20text%2C%20cite%20the,not%20include%20citations%20in%20abstracts

5) In methods pl include the sample size.

6) Exclusion criteria needed to be added.

Minor issues:

1) We included two attributes potentially associated with self-stigmatization. First, medication type, which included antidepressants and two different names that could be used to describe the same family of antipsychotics to treat MDD. It is difficult to follow this sentence. Recommend rephrasing

General comments:

While the data from this article is informative. Study methodology is unclear with missing information to reproduce the study. Also, study could be more valid if questionnaire used included psychiatrist/ physician involvement in recommending the medication and discussing with patient

Reviewer #4: This article offers valuable insights into self-stigmatization and how it interacts with treatment and medication compliance. Although some of the conclusions were difficult to grasp, overall, the article successfully identifies the impact of self-stigmatization on the treatment of specific mental health issues using a decent sample size.

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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 #2: No

Reviewer #3: Yes: Mallikarjuna Bagewadi Ellur

Reviewer #4: 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.

Self-stigmatization and treatment preferences: Measuring the impact of treatment labels on choices for depression medications

PONE-D-24-07744R2

Dear Dr. Gonzalez Sepulveda,

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,

Souparno Mitra, M.D.

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 #2: All comments have been addressed

Reviewer #4: 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 #2: Yes

Reviewer #4: Yes

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

Reviewer #2: Yes

Reviewer #4: 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 #2: Yes

Reviewer #4: 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 #2: Yes

Reviewer #4: 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 #2: Thank you for the opportunity to rereview "Self-stigmatization and treatment preferences: Measuring the impact of treatment labels on choices for depression medications". All the requested review comments by all the reviewers were adequately addressed. All the suggested recommendations were done and addressed appropriately.

Reviewer #4: The examination underscores the significance of psychoeducation and shared decision-making in addressing self-stigmatization and enhancing the acceptance of treatment among individuals with Major Depressive Disorder (MDD). By ensuring that patients are well-informed and actively engaged in their treatment choices, healthcare providers can effectively confront stigma-related barriers and facilitate more proficient management of depression.

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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 #2: No

Reviewer #4: No

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