PONE-D-23-36010Digital Mental Health Service engagement changes during Covid-19 in children and young people across the UK: presenting concerns, service activity, and access by gender, ethnicity, and deprivationPLOS ONE

Dear Dr. Salhi,

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2. Thank you for stating the following in the Competing Interests section: 

"I have read the journal's policy and the authors of this manuscript have the following competing interests:

Dr Louisa Salhi and Aaron Sefi are currently employed by Kooth digital Health - the service that the service data was extracted from. Dr Louisa Salhi also holds honorary researcher status at the University of Kent.

Dr Santiago de Ossorno Gardia and Lily Mainstone-Cotton were previously employed by Kooth Digital Health at the time of data extraction but are no longer employed by Kooth.  

All other authors have no conflict of interest."

We note that one or more of the authors are employed by a commercial company: Kooth digital Health.

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Additional Editor Comments:

I have seen the paper and the suggestions from the reviewers. In particular, I urge the authors to pay attention to the indications provided by Reviewer 2, who highlighted several critical points. Additionally, I encourage the authors to utilize a proofreading service, given the numerous errors in the text and the usage of the English language.

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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: 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: No

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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: No

Reviewer #2: No

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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: This is a potentially valuable descriptive study addressing a topic of high policy priority. The study appears to have been appropriately conducted, but the write up needs a significant overhaul. There are multiple errors throughout the manuscript that suggest inadequate attention to copy editing prior to submission. These errors take the form of the inclusion of legacy placeholder text, incorrect referencing of a table/figure, nonsensical sentences and a disconnect between the number of studies referred to (multiple) and supporting citations (singular). Other potential improvements include: framing this more explicitly as an evaluation of changes observed in one digital mental health service rather than digital mental health services more generally (eg modify title, describe role of Kooth in broader ecosystem, discuss generalisability to digital mental health services more widely); shorten discussion and focus on both lessons for Kooth and UK/international digital mental health services; and add nuance to statements about attractiveness of Kooth type services by referencing the youth and digital mental health services preference literature.

Reviewer #2: This study investigates CYP service use before and during the COVID pandemic. It stratifies its findings by type of use, reason for accessing service and demographic variables. Overall service use increased rapidly at pandemic inception but then reduced, though remained higher than pre-pandemic levels, time-series analysis revealed overall small reduction in rate of change of use during pandemic.

Introduction

Can the intro better relate to the research questions more clearly, why is referral route an important research question to ask? How does RQ about presenting concerns relate to the first paragraph.

“. Some countries responded with a national digital support provision for mental health in the face of the pandemic10, but it is not yet clear how well these services were utilized, or whether access was equitable across sociodemographic groups.”

Is Kooth a UK “national digital support provision” - if so, probably should state in the introduction and explain a little bit about how CYP can access this service to orient the reader.

Methods

Outcome variable

“Service access contacts was our outcome of interest by month. To calculate the rate of contact per user, we identified the number of active users on the platform (i.e., denominator) by counting the number of users accessing the service at least once each month between June 2019 to April 2021.”

For clarity can you state that the numerator was the number of contacts, denominator number of active users providing a rate of contacts/user.

CCGs:

“A total of 34 regions structured by Clinical Commissioning Groups (CCG) with unchanged resource contracts were selected from a total of 97 (N=5 decreased; N=58 increased); the selection criteria of regions was used to prevent biases due to changes in resources that may affect the demand and capacity of the online service during the pandemic (resource increase or decrease during the observational period). The study selected only regions of the service that had the same allocated number of resources before and during the pandemic, remaining therefore constant during the period.”

You need to explain what a CCG is and how it fits into the UK healthcare system to a non-UK audience or any reader who is unaware of how services are commissioned in the UK.

What do you mean by resource allocation – resource allocated to Kooth, resource allocated to the CCG?

How did you know resource allocation had increased decreased? please state and cite where this information was obtained if relevant.

This will then make it clear why you selected only 34/97 CCGs, which shall reduce the number of users included in the analysis.

IMD

Typically, this is known as the index of multiple deprivation, no deprivations.

Can you clarify that no part of the user postcode was used to determine the IMD.

Can you clarify what you mean by “partially disclosed” when you state “We used the average IMD rank of each CCG location included (out of a possible 191(ranks?)) to calculate deprivation quintiles (higher ranks are least deprived) for each user in relevance to their area (partially disclosed at registration and group by CCG).”

Why are 29.4% of IMD data missing for CCGs, given this information is publicly available?

Gender

Can you describe for the reader what genders are included in the terms agender and gender fluid.

Presenting concerns

“A total of 118 reported different presenting concerns were identified for the study. Those were grouped into five high-level categories aligned with previous literature on the mental health impact of the pandemic and allowed for sufficient observations within each category to track trends over time.”

This information is presented later on

“The dataset presented 118 different types of presenting concerns, which were grouped into five categories representing the main mental health impacts of the Covid-19 pandemic for CYP identified in previous literature (Supplementary Table 2).”

Can you present this information only once and state what the categories are, which authors grouped them and how disagreements were resolved.

Analysis

“For this, we included a binary coded variable in the model which represented the pandemic period (i.e., model step change), as well as an interaction term between time and intervention which models a slope change. “

In the interaction term, what was the reference period?

General point:

Could the time Kooth commenced in a CCG affect rate of change pre-pandemic, for example rate of change might be higher upon commencement and then stabilise.

Results

The study would benefit from a description of how the sample were selected, the number excluded from CCG selection aswell as the number excluded from lack of consent and any other exclusion criteria. Can you also state the proportion of registered users who transferred to active users and therefore included in the analysis (some may register but never contact the service directly or indirectly).

We are also missing N’s, would help interpretation of the table in tables 3, 4 and 5 confidence intervals. For example in table 5 small Ns in Q2, Q3 and Q4 are indicated by wide intervals.

Supplementary Table 3 is missing from the supplementary.

Main findings:

“When comparing trends in the periods, before the pandemic there was evidence of a 25% (95% CI: 9%- 44%) increase rate in contacts per user per month (p=.001), this reduced to a 21% (95% CI: 4%-41%) increase per month during the pandemic” – missing a fullstop.

“this reduced to a 21% (95% CI: 4%-41%) increase per month during the pandemic”

Where is this statement reflected in table 1 and figure 1?

Overall, the figure shows a gradual increase in use of Kooth that sharply increases at the onset of the pandemic then gradually decreases, but does not return to pre-pandemic levels. The figure might benefit from a dashed line which shows what Kooth contacts would have looked like had the pre-pandemic slope continued. This may visually explain why the rate ratio of slope change in table 1 indicates a relative decrease in use (RR<1).

Similar questions about the same statistics for direct and indirect contacts.

Figure 2

Why in figure 2 do the pre-pandemic slopes by type of presenting concern indicate decreasing contacts per month, but in figure 1 when presented overall, indicate increasing contacts per month?

Are these sub-populations, if so this needs to be stated?

An explanation of external needs to be included in the main results and not just in the supplementary to aid the reader.

Needs to be reproduced with the X axis and the legend presented suitable for publication.

From the figure it appears there is a slope change in self-harm/suicidality that was non-significant in the model, is it worth mentioning this?

Again, lines to indicate what Kooth use would have looked like had the pre-pandemic slope continued may facilitate understanding of the table statistics.

Discussion

Overall, this section needs to be rewritten prior to publication. The results need to be summarised more clearly and concisely. As do the main implications of the findings.

Example Very long and incomplete sentence. “We found that service activity changed and increase during the pandemic but changes in the referral sources and the way people access to pathways of care more generally may have impacted the increase in service access and demand, as contacts per users were higher in pre-pandemic activity when compared, our data suggest that dramatic changes in the healthcare system are likely to impact too digital ecosystems of support, even when operating anonymously and with relatively ease of access online, interoperability between services may be important in order to .” Please be more specific here and link your interpretation to the specific result your draw your inference from.

Please refer to this paper Effects of the COVID-19 pandemic on primary care-recorded mental illness and self-harm episodes in the UK: a population-based cohort study (thelancet.com)

This examines trends in MI presentations by age and suggests that self-harm presentations were alarmingly low. Potentially the increased contacts seen in Kooth provided a resource for children and adolescents who were unable/unwilling to present to primary care. The paper also provides an example of how to visualise expected and observed trends, which the authors may find useful.

I am not sure we can draw firm conclusions from the CCG IMD analysis about the facility of Kooth to reach deprived populations - each CCG represents 200 to 500K residents, pops are much larger in London CCGs, within those areas deprivation will vary widely, without a more localised measure of deprivation it is difficult to be certain that Kooth did truly reach these groups using the data in this study. However, this is noted in the limitations.

Do you have any hypotheses as to why Asian and mixed CYP did not increase use at pandemic onset?

In the final conclusion paragraph the authors state “Whilst the cause for the decrease in access as the pandemic continued is not known” – I’d really like them to suggest some possible hypotheses for why this might be: what about pandemic apathy/ of users, pandemic apathy of CYP settings to promote Kooth, increasing resilience of CYP as initial crisis passed, or bias towards larger numbers of less active users each month (those registered for long periods of time) as time progressed?

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Reviewer #1: Yes: Matthew Philip Hamilton

Reviewer #2: No

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PONE-D-23-36010R1Digital Mental Health Service engagement changes during Covid-19 in children and young people across the UK: presenting concerns, service activity, and access by gender, ethnicity, and deprivation

PLOS ONE

Dear Dr. Salhi,

Thank you for submitting your revised manuscript to PLOS ONE.

The manuscript has been evaluated by a new reviewer, and their comments are available below.

The reviewer has made a number of suggestions for further revisions to the manuscript. Please note that we do not consider any of the requests to be mandatory, especially those to add citations, but you may agree that they would improve the manuscript. Please also ensure that the main manuscript file does not contain a Data Availability Statement that differs from the previously agreed one in the submission form.

Please submit your revised manuscript by Dec 23 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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Patrick Goymer

Staff Editor

PLOS ONE

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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.

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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 #3: (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 #3: Yes

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

Reviewer #3: I Don't Know

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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 #3: 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 #3: 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 #3: I found this a well written, interesting and useful paper (as a researcher who has done some work in this area and a practitioner working with children and young people), and felt I learned something from reading it. I commend the authors’ efforts to make use of available routine clinical data for research purposes, and organizational learning (and the fact it support this learning should perhaps be acknowledged more). I appreciate also the manuscript has already been reviewed, at least once, and joining at this stage, there is the potential I offer quite a different opinion.

Overall, I thought the work reported was of good quality and ambitious in scope, thus warranting publication. Notwithstanding this overall appraisal, there were some areas I thought it could be further developed and list them below.

1. I think more detail could be provided about the type of research this is and references to support the approach taken, i.e., for me, it is a clinical data mining (CDM) study. So, the work of Epstein for example could be cited (see: Epstein, I. (2009). Clinical data-mining: Integrating practice and research. Oxford University Press.). There are also other sources that may be suitable, e.g., Davenhill, R., & Patrick, M. (Eds.). (1998). Rethinking clinical audit: The case of psychotherapy services in the NHS. Psychology Press.

2. One area I thought more could have been said, in the context of the introduction and discussion, was in relation to the voices of young people. I thought the extent to which this digitally based support may be preferable during the context of the pandemic (i.e., with physical distancing etc.), but not outside of it was glossed over, and there may be value in citing additional studies which addressed the ‘client’ or stakeholder perspective on digitally delivered support, and how this interlinks with other forms of support (see, e.g., Maddison, C., Wharrad, H., Archard, P. J., & O’Reilly, M. (2024). Exploring young people’s perspectives on digital technology and mental healthcare: pilot study findings. Mental Health Practice, 27(1).) Also, are there ways in which this client voice could be better integrated into this type of CDM study in future?

3. A few more minor issues. Consider how statistical significance is referred to on pp. 16-17 (see Benjamin, D. J., Berger, J. O., Johannesson, M., Nosek, B. A., Wagenmakers, E. J., Berk, R., ... & Johnson, V. E. (2018). Redefine statistical significance. Nature human behaviour, 2(1), 6-10). At the beginning of the discussion, consider wording used (The paper didn’t itself investigate, but rather the research reported within it did …). Towards the end of the paper, I’m unsure I agree with the authors that it showcases the value of the service, so much as provide valuable data about access to the service and how it is used. Here, the ‘local’ genesis of the research is perhaps worth acknowledging, i.e., it was undertaken in a single (large) organization and, as much as anything, supports organizational learning.

Beyond this, I think the point about data availability is perhaps something that the authors want to liaise with the editorial team about, as it appears the authors are working with an anonymized dataset and I’m unsure why this wouldn’t be made available to the public, for example, owing to a freedom of information request. Where Kooth as an organization sits in relation to FoI legislation is, for me, another matter, i.e., they are not a public authority, but they are funded by public monies, so, for me at least, there would be an argument to make the anonymized data available, at least in the interests of transparency for research practice.

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Reviewer #3: No

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Digital Mental Health Service engagement changes during Covid-19 in children and young people across the UK: presenting concerns, service activity, and access by gender, ethnicity, and deprivation

PONE-D-23-36010R2

Dear Dr. Salhi,

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.

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