-->PONE-D-24-28645-->-->Prevalence of depression, anxiety and its association with socio-demographic factors among adolescents aged 15 to 21 in Mymensingh division, Bangladesh: Results from a cross-sectional study-->-->PLOS ONE

Dear Dr. Islam,

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

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-->5. Review Comments to the Author

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Reviewer #1: Thanks for receiving the opportunity to review your paper. Overall, I appreciate the thoroughness and importance of your study on Prevalence of depression, anxiety and its association with socio-demographic factors among adolescents aged 15 to 21 in Mymensingh division, Bangladesh: Results from a cross-sectional study. However, this manuscript must undergo minor revisions before it can be considered for publication.

The title needs to be modified; most of the research shows that adolescents are between 10-19 years or mention in title late adolescents age. The title should be Prevalence of depression, anxiety, and its association with socio-demographic factors among late adolescents age in Mymensingh division, Bangladesh: A cross-sectional study.

In abstract heading, introduction needs to change into background and keywords should be in MeSH form and alphabetical order.

Introduction: This introduction provides a good overview of the relevance of depression and anxiety among adolescents in Bangladesh. However, some references can be updated or expanded to reflect more recent studies, particularly those related to global mental health trends. The focus on Bangladesh is important, but perhaps elaborating more on the global context before zooming into Bangladesh could provide better framing

In introduction section line 60-65 needs to verify According to the World Health Organization (WHO), depression and anxiety are the most common mental health disorders among late adolescents (15-24); where depressive disorders are characterized by sadness, loss of interest, feelings of guilt or low self-esteem, disturbed sleep or appetite, feelings of tiredness or poor concentration and anxiety disorders are characterized by feelings of fear, dread, and uneasiness (5).With the provided reference, especially for the age group.

Methodology: The methodology section of the manuscript provides a detailed account of the study design and data collection process. However, several aspects need clarification and improvement to enhance the scientific rigor and reproducibility of this study.

The total number of 400 subjects is appropriate, but more detail is needed about sample size calculation.

Author need to mention how many researchers were involved in the data collection.

More information about potential biases in data collection, such as how respondents were recruited, would enhance transparency.

Results: Table 1 needs to cite in text.

Discussion: The discussion does a good job of comparing your findings to existing literature. However, the implications of your findings for future policy or practice could be expanded. What specific actions should be taken by policymakers or practitioners in Bangladesh as a result of your findings? Consider expanding on the limitations of the cross-sectional design in more detail. Additionally, potential avenues for future research based on your findings could be elaborated upon.

Conclusion: The conclusion is clear but could benefit from further emphasizing the practical applications of the study. For instance, what specific steps can be taken to improve mental health outcomes based on your findings?

Reviewer #2: Dear Young Graduates,

Thank you for your valuable work on researching adolescents' mental health issues. Your effort is commendable, and I appreciate the dedication that went into this study. However, I believe some revisions are required to translate it into a publishable paper as follows:

1. Introduction: It would be beneficial to include a paragraph that articulates your motivation for this study and outlines its novel and unique contributions. This will set a strong foundation for your readers.

2. Methodology:

o In the subsection on study design, setting, and participants, you've mentioned the use of a multi-stage sampling technique. Please provide a justification for this method, along with relevant references.

o You stated that Upazilas were randomly selected in the second stage, followed by unions and villages. However, the total number of Upazilas, unions, and villages and how many of them were chosen are not mentioned. Could you elaborate on the random selection process? Additionally, why did you limit your recruitment to rural adolescents, excluding urban and suburban populations? With potentially hundreds of thousands of adolescents available, how did you arrive at the 400 participants? Clarifying whether this was based on convenience or a first-come-first-served approach was adopted.

3. Measures: The variables you've included require justification and references. Consider discussing why other relevant variables, such as the family history of depression or anxiety, educational outcomes, financial stress, household wealth, physical health indicators (e.g., BMI), drug addiction, frustration about life or love, etc. were not measured.

4. Statistical Methods: Your paper currently lacks detail on the statistical methods used. Please include a discussion of ordinal logistic regression, highlighting its appropriateness for this study compared to other methods like OLS, multinomial logit, or probit, etc.

5. Conceptual Framework: Instead of presenting your conceptual framework in the Statistical Analysis section, please create a dedicated section after the introduction. Moreover, Figure 1 indicates that socio-economic factors have both direct and indirect effects on depression and anxiety via lifestyle factors. If this is the case, you should illustrate how the indirect effects occur through your ordinal logistic regression using instrumental variables. If you wish to simplify the model due to insufficient instrumental variables in your dataset, consider modifying the figure to show only direct effects.

6. Language Sensitivity: In your script, terms like “No education” and “father/mother had no education” may come off as imprudent. Consider using “without formal education” and father/mother without formal education” instead for a more respectful tone.

7. Results Section: On pages 11-12, you mention that “The ratio of moderate to severe depression was higher in (i) males vs. females, (ii) older adolescents (19-21 years) vs. years age groups, … , with severe anxiety (Table 2)” which are meaningless. Similarly, on pages 14-15, mentions that “The proportion of moderate to severe anxiety was higher in (i) males vs. females, (ii) older adolescents (19-21 years) vs. 15-16 years age groups, (iii) Muslim vs. non-Muslim…..” Please rewrite these findings in a more digestible manner.

8. Specifications or robustness tests: Please include specifications or robustness tests for your ordinal logistic regression results to validate your findings.

9. Discussion: Instead of solely comparing your findings to other studies, begin each paragraph in the discussion section by explaining your own results on relevant variables before making comparisons.

10. Policy implications, limitations of the study, and suggestions for future research: Your study lacks discussion on policy implications, limitations of the study, and suggestions for future research. Add them in the conclusion section in detailed paragraphs.

Remember, research is an ongoing learning journey. I hope these suggestions aid your growth and refinement in academia. I look forward to seeing your revised manuscript soon!

Reviewer #3: The authors have done commendable work in addressing a crucial and often under-researched issue of adolescent mental health in Bangladesh, providing valuable insights into the prevalence and socio-demographic factors associated with depression and anxiety. To further strengthen the manuscript, the following suggestions are offered: enhancing the clarity and structure of the abstract by including specific numerical findings and organizing it into subsections; refining the introduction to focus more on the local context and research gaps; providing a more detailed description of the sampling strategy, inclusion criteria, and validation of tools in the methods section; streamlining the presentation of results with a focus on significant findings, and incorporating stratified analyses; deepening the discussion with a critical comparison to existing literature and a more thorough exploration of implications for policy; and finally, including measures of effect size, interaction terms, and model fit diagnostics in the statistical analysis

1. Abstract

o The abstract lacks structure and detailed quantitative results. Although it mentions the prevalence of depression and anxiety, it does not provide sufficient breakdown of findings or statistical measures.

o The objectives are stated generally, and the results do not clearly specify the key predictors or effect sizes.

• Recommendations:

o Structure: Use subheadings like "Background," "Methods," "Results," and "Conclusions" for better clarity.

o Be Specific About Prevalence: Instead of saying, “Almost half (47.8%) of adolescents experience depression and over a third (32.8%) experience anxiety,” specify the severity levels, e.g., "47.8% had depression (---% moderate, ---% moderately severe, ---% severe), and 32.8% had anxiety (---% moderate, ---% severe)."

o Include Key Predictors: Mention the main predictors found in the regression analysis. For instance, "Depression was significantly associated with father's education level (p < 0.05) and lack of regular physical activity (p < 0.01)."

o Quantify the Associations: Report odds ratios (ORs) for key associations. For example, "Adolescents whose fathers had no education were --- times more likely to experience depression (95% CI: ---–---)."

2. Introduction

o The introduction is broad and spends too much time on global mental health statistics without quickly narrowing down to the local context in Bangladesh.

o The research objectives are somewhat buried and not explicitly detailed.

• Recommendations:

o Focus on Local Context Early On: Begin by stating the lack of adolescent mental health research in Bangladesh, specifically in rural areas and among older adolescents (19-21). Use national statistics from the 2019 Bangladesh National Mental Health Survey early in the introduction.

o Define the Research Gap Clearly: Emphasize the gaps that this study addresses, such as limited research on out-of-school adolescents or those living in rural areas.

o Explicit Research Objectives: State the objectives clearly. For example: "This study aims to (1) estimate the prevalence of depression and anxiety among adolescents aged 15-21 in Mymensingh, and (2) identify socio-demographic factors associated with these mental health conditions, including parental education, physical activity, and rural versus urban residence."

3. Methods

o The sampling process and criteria for inclusion/exclusion are not adequately detailed, making it difficult to assess the study's generalizability.

o There is insufficient explanation of the tools used (PHQ-9 and GAD-7) and how they were validated for use in the local context.

• Recommendations:

o Clarify Sampling Strategy: Expand on the multi-stage sampling technique. For example, describe the process for selecting districts, Upazilas, and villages, and how many participants were recruited from each stage. Specify if any steps were taken to ensure diversity in the sample.

o Explain Inclusion/Exclusion Criteria Clearly: Mention if adolescents with ongoing mental health treatments or specific conditions were excluded. Clarify how participants were approached, especially if they were out-of-school.

o Validation of Tools: Explain the reliability and validity of the PHQ-9 and GAD-7 scales in the local context. If these tools were used in other Bangladeshi studies, provide citations. Include any cultural adaptations made to the tools.

o Data Availability: Mention where the data can be accessed post-publication (according to PLOS ONE requirements) or explain the ethical restrictions.

4. Results

o The presentation of results is somewhat dense and difficult to follow, especially with large tables containing many variables. Non-significant variables are listed without further discussion.

o There is minimal stratification of results by key factors like gender, rural/urban residence, or age.

• Recommendations:

o Streamline Tables: Focus on significant results in the main text and relegate non-significant findings to supplementary materials. For example, condense Table 2 by only presenting variables with p-values < 0.05 and showing their odds ratios.

o Include More Stratified Analyses: Break down the prevalence of depression and anxiety by gender and location (rural vs. urban). For example, report if males had higher depression rates in rural areas than females.

o Graphical Representation: Add visual elements like bar charts or forest plots to make the results more accessible. For example, display odds ratios with confidence intervals for key predictors.

5. Discussion

o The discussion is more of a summary than a critical analysis. It does not adequately engage with existing literature to explain why some findings may differ from other studies.

o There is minimal exploration of the implications of the findings for policy and practice in Bangladesh.

• Recommendations:

o Engage Critically with Other Studies: Compare findings with previous studies in Bangladesh and nearby regions. For example, discuss why the current study found higher depression rates in males, while other studies reported higher rates in females. Suggest possible cultural, social, or methodological reasons for these differences.

o Implications for Policy: Go beyond suggesting that mental health services need improvement. Provide specific recommendations, such as implementing school-based mental health programs or integrating mental health education in rural communities.

o Explain Limitations Thoroughly: The current limitations section is brief. Discuss potential biases (e.g., self-report bias), limitations due to the cross-sectional design, and any sampling issues that may affect generalizability. For example, mention the overrepresentation of rural adolescents and how it might skew the findings.

o Future Research Suggestions: Recommend longitudinal studies or qualitative research to explore causality and understand the lived experiences of adolescents with mental health issues.

6. Conclusion

o The conclusion restates the findings without providing a strong summary of their implications or suggesting next steps.

• Recommendations:

o Summarize Key Findings Clearly: For example, "This study found high prevalence rates of depression and anxiety, particularly among rural adolescents and those with low parental education, indicating an urgent need for targeted interventions."

o Convey Policy Recommendations Briefly: Instead of generic suggestions, be specific, e.g., "Policy efforts should focus on training healthcare workers in rural areas to identify and manage adolescent mental health issues."

o Avoid Repetition: Do not repeat points already discussed in detail in the results or discussion. Instead, provide a concise statement on the significance of the findings.

7. Tables and Figures

o Some tables are too detailed, making them difficult to interpret quickly. There is no use of figures to illustrate key findings.

• Recommendations:

o Condense Tables: For example, in Table 2, highlight only significant results in the main manuscript. Move less relevant details to supplementary materials.

o Add Figures: Consider using a forest plot to illustrate the odds ratios and confidence intervals from the logistic regression. Add bar charts for the prevalence of depression and anxiety across different age groups or by gender.

8. Statistical Analysis

o The analysis could benefit from including measures of effect size and considering interactions between key variables.

• Recommendations:

o Include Effect Sizes (e.g., Cramér's V for Chi-Square Tests): This would add context to the significance tests.

o Test the Proportional Odds Assumption: For ordinal logistic regression, confirm that this assumption holds. If not, consider using alternative models.

o Include Interaction Terms: Explore interactions, for example, between gender and rural residence, to see if the effects of socio-demographic factors on mental health outcomes differ across subgroups.

o Model Fit Diagnostics: Report Pseudo R-squared values or other model fit statistics for the ordinal logistic regression.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes:  Adrija Roy

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Attachments

Attachment

Submitted filename: Plos Comment for Author.docx

-->PONE-D-24-28645R1-->-->Prevalence and socio-demographic correlates of depression and anxiety among late adolescents (15 to 21 years) in Mymensingh division, Bangladesh: A cross-sectional study-->-->PLOS ONE

Dear Dr. Islam,

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.

Please check the comments of the learned reviewer (Amit Roy). Reply those comments and fix the text accordingly. 

Please submit your revised manuscript by Feb 12 2025 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'.
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• 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,

AKM Alamgir, PhD

Academic 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 #1: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #3: 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

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: 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: No

Reviewer #2: No

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 #1: Yes

Reviewer #2: No

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 #1: Thank you for the opportunity to review your research paper. I wish you further success and look forward to seeing your work in print.

Reviewer #2: Dear Authors,

Thank you for your revision. However, it is not yet adequate and complete. Please revise your manuscript further, addressing the following suggestions:

1. In the abstract, you use different p-value specifications (e.g., OR = 0.15; 95% CI = 0.03-0.75, p = 0.021 or OR = 0.06; 95% CI = 0.01-0.22, p < 0.000). The p-value format should be consistent. Please use a uniform presentation, such as "<0.05" instead of "p = 0.021," throughout the abstract.

2. I asked you to add a new section after the introduction for a Conceptual Framework and to discuss it in detail, explaining how each variable in the diagram relates to the prevalence of depression and anxiety. Instead, you added a brief summary. Please address this issue by providing a detailed, thoughtful discussion in 3-6 paragraphs in a separate Conceptual Framework section after introduction.

3.

4. In the Methodology section, I requested an explanation of the random selection process of participants. However, you did not provide details on the methodology used, such as whether a lottery or random number generation was employed for random selection at each stage of sampling. Furthermore, I raised the question of how you choose 400 participants when there are potentially hundreds of thousands of adolescents available. There was no response regarding this crucial issue. Please explain in detail how the 400 participants were selected from the millions of adolescents in the study area, ideally in a separate paragraph. If randomly selected, which database you used and how did you access it, if not which other method.

5. I recommend that you justify and reference the variables you included in the study. “Please discuss why other relevant variables—such as family history of depression or anxiety, educational outcomes, financial stress, household wealth, physical health indicators (e.g., BMI), drug addiction, frustration about life or love, etc.—were not measured.” In your response, you stated that justification and references were provided in the methodology section. However, I found no such discussion in the revised manuscript. You need to clarify why the variables you selected were chosen and explain why others were excluded, citing relevant studies or references.

6. Regarding statistical methods, your paper currently lacks detail on the methods used. You mentioned that ordinal logistic regression was discussed and compared with other methods to highlight its appropriateness for the study, but I could not find any detailed explanation of this in the revised manuscript. Please include a statistical methods section with a discussion of ordinal logistic regression, including its equation and parameters.

7. In response to my comment 8, you mentioned that "robustness tests have been included in the manuscript." However, I could not find any robustness tests or results in the revised manuscript. Additionally, you have 23 variables in the study, but only 8-9 variables are included in the ordinal logistic regression, which suggests that your model may be manipulated. To avoid bias, you need to incorporate all explanatory variables mentioned in the descriptive statistics and run the ordinal logistic regression with these variables included. Also, variables such as age, gender, and family income are crucial. Why were they excluded from the regression? These variables need to be included, and the regression should be rerun to ensure accurate results.

8. In the discussion section, you included a lot of information from other research but failed to properly discuss your own findings. You need to first compare your findings with those from other studies, and then explain how the local context of your study area may account for differences from other research. This comparison has not been done adequately.

9. In comment 10, I asked you to add a discussion on policy implications, study limitations, and suggestions for future research in the conclusion section. Unfortunately, no improvement has been made in this regard. Please rewrite the conclusion in 3-5 detailed paragraphs: one sentence on background and methodology, one sentence on results and findings, one on policy suggestions based on your findings, one on limitations, and one on future research. This should be done thoroughly.

10. Your finding that "unmarried adolescents, mobile phone users, rural adolescents, and those whose fathers and mothers were without formal education were more likely to experience moderate to severe depression and anxiety than their counterparts" should be reflected in policy suggestions. In separate sentences, provide specific policies, programs, or actions that can address each of these variables and help improve mental health outcomes.

11. In the abstract, you mentioned that "depression was more likely to be associated with those who were businessmen and day laborers." This should be analyzed in the results section. You need to explore why these groups are vulnerable to depression and suggest policies to reduce mental stress among these working groups.

12. The last paragraph you added in the discussion should be rewritten in clearer, more readable language and placed in the limitations paragraph of the conclusion.

13. In my previous comments 7 and 8, I requested clarification and made suggestions to improve readability. However, the revised manuscript still contains sections that are not audience-friendly or easy to read. Please revise these paragraphs to improve clarity and coherence.

I look forward to receiving the revised manuscript.

Reviewer #3: The manuscript effectively addresses a critical and under-researched issue of adolescent mental health in Bangladesh, providing valuable insights into the prevalence of depression and anxiety and their socio-demographic correlates. The authors have made significant revisions based on reviewer feedback, improving the structure, clarity, and scientific rigor of the study. Key strengths include the detailed statistical analysis with effect sizes, the inclusion of specific policy recommendations, and a critical comparison with existing literature. However, a few minor improvements can further enhance the manuscript's quality. These include explicitly clarifying whether the proportional odds assumption was tested, and expanding on the implementation challenges of proposed policies in the Bangladeshi context. Overall, the manuscript is well-prepared and, with these refinements, is suitable for publication, contributing meaningfully to the global conversation on adolescent mental health.

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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.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes:  Dr. Adrija Roy

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<p>Prevalence and socio-demographic correlates of depression and anxiety among late adolescents (15 to 21 years) in Mymensingh division, Bangladesh: A cross-sectional study

PONE-D-24-28645R2

Dear Dr. Islam,

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Kind regards,

AKM Alamgir, PhD

Academic Editor

PLOS ONE

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