PONE-D-24-44639AQoLS-Brief: development and psychometric properties of a short version of the Alcohol Quality of Life ScalePLOS ONE

Dear Dr. Luquiens,

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kindly see the reviewers comments and address their queries.

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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: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: No

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: Introduction

1. Line 43: Add a concise explanation of the COSMIN criteria and highlight their relevance.

2. Line 43: While the Alcohol Quality of Life Scale (AQoLS) is described as having excellent internal consistency, other psychometric properties (e.g., test-retest reliability, validity in different populations) of both the original and brief versions are not addressed. Adding this would make the justification for the AQoLS more robust.

3. Line 54: ‘A shorter version would be more convenient for both researchers and users.’ -- What was the rationale for using the shorter version of AQoLS-Brief? It is not clear. Clearly state the research gap this study aims to fill.

4. Provide more specifics on how the AQoLS-Brief will facilitate discrete choice experiments. Will it reduce complexity or address specific methodological challenges? This clarification will underline the importance of this study.

Study Design and Methods

1. Line 81: Write the full abbreviation of TRAIN study.

2. Line 97: ‘Patient had to be aged 18 to 65 with current AUD, according to the DSM-5, classed at least as high drinking risk level (men: alcohol consumption >60 g/day; women >40 g/day) as regarding the alcohol consumption in the last 4-week drinking period.’ -- break it into two lines.

3. Line 100: Why these specific criteria (e.g., 7-30 days abstinence) were selected. Does this enhance the reliability of baseline data, reduce variability, or align with clinical practice?

4. Please note that the inclusion criteria started from lines 97 – 103. Line 100: include ‘also’ – Inclusion criteria also included no benzodiazepines use for at least 3 days prior to inclusion, to avoid interference with alcohol intoxication or withdrawal medication on the neuropsychological assessments, and any recall bias on drinking.

5. Consider adding more discussion on how the AQoLS-Brief was developed with input from patients and how this ensures its relevance.

6. Line 171: Write the full abbreviation of MoCA score.

Discussion

The discussion could better connect the results to the study’s objectives and implications for future research or clinical practice. Discuss how the AQoLS-Brief improves on the original AQoLS in terms of usability and application. Address potential limitations of the study (e.g., sample representativeness, reliance on specific statistical rules for item selection) and suggest how they could be addressed in future research.

Reviewer #2: I have also attached a document with the detailed reviews.

Thank you for the opportunity to review this manuscript. The current study creates and validates a brief version of the Alcohol Quality of Life Scale (AQoLS-Brief) in a sample of recently detoxified patients with alcohol use disorder. Please find me critiques below.

• The external validity variables, besides the MoCA, were very focused on alcohol use-related constructs. The variables included are good, but some additional variables not related to alcohol specifically but that map onto some of the subscales or global quality of life would strengthen the convergent and discriminant validity analysis (Clark & Watson, 2019). Candidate variables could include scales of global quality of life, depression, anxiety, physical health pr medical history, relationship functioning, socioeconomic status, sleep quality, and so on. If none of these variables were measured in the original data collection, then at the very least the lack of these measures should be included as a limitation.

o Clark, L. A., & Watson, D. (2019). Constructing validity: New developments in creating objective measuring instruments. Psychological Assessment, 31(12), 1412–1427. https://doi.org/10.1037/pas0000626

• Related to the point above, it would be useful to examine validity predictors in a multiple regression together (as opposed to bivariate correlations only). This would allow for parsing apart which constructs are most strongly/uniquely associated with the AQoLS-Brief.

• I am confused why it was hypothesized that there would be no correlation between the AQoLS-Brief and cognitive impairment. Cognitive impairment is a well-established correlate of alcohol use disorder (Bernardin et al., 2014; Wang et al., 2023), even after recovery (Stavro et al., 2013). The current manuscript even cited an article demonstrating the utility of the MoCA as a screening tool for alcohol-dependent individuals, and the data comes from a clinical trial in which patients undergo a cognitive training program. There is also evidence that cognitive impairment and quality of life are negatively associated (Hill et al., 2017). What is the rationale that alcohol-related impairment in life would not be associated with cognitive impairment?

o Bernardin, F., Maheut-Bosser, A., & Paille, F. (2014). Cognitive impairments in alcohol-dependent subjects. Frontiers in psychiatry, 5, 78.

o Hill, N. L., McDermott, C., Mogle, J., Munoz, E., DePasquale, N., Wion, R., & Whitaker, E. (2017). Subjective cognitive impairment and quality of life: a systematic review. International psychogeriatrics, 29(12), 1965-1977.

o Stavro, K., Pelletier, J., & Potvin, S. (2013). Widespread and sustained cognitive deficits in alcoholism: a meta‐analysis. Addiction biology, 18(2), 203-213.

o Wang, G., Li, D. Y., Vance, D. E., & Li, W. (2023). Alcohol use disorder as a risk factor for cognitive impairment. Journal of Alzheimer's Disease, 94(3), 899-907.

• I have some reservations about the decision to exclude factorial analysis and believe that a confirmatory factor analysis (CFA) should be estimated. I understand trying to retain the original 7-dimension structure, but surely the intention of this scale is to be used as a screen for general alcohol-related quality of life impairment, suggesting the measure will be treated as a single factor scale. A CFA would inform how the measure performs as a single, unidimensional factor of alcohol-related quality of life impairment (Briggs & Cheek, 1986; Simms, 2008). Examining factor loading strength and patterns of the brief dimension could even be used to guide item selection. Currently as it stands, the two selection criteria tell us whether the items selected are representative of their original scale? A CFA would tell us do these selected items hang together as a single construct that can be used meaningfully? Moreover, the original studies examining psychometric performance of the AQoLS reported: “The preliminary principal component analysis indicated a substantive principal dimension accounting for 42 % of the variance, thus indicating the appropriateness of a total AQoLS score summing the items” (Luquiens et al., 2016). While a 7-factor solution was ultimately settled on, it seems that testing a single factor CFA is appropriate given some of the preliminary work with the full measure and the purpose of using brief measures more broadly.

o Briggs SR, & Cheek JM (1986). The role of factor analysis in the development and evaluation of personality scales. Journal of Personality, 54, 106–148.> doi: 10.1111/j.1467-6494.1986.tb00391

o Luquiens, A., Whalley, D., Laramée, P., Falissard, B., Kostogianni, N., Rehm, J., ... & Aubin, H. J. (2016). Validation of a new patient-reported outcome instrument of health-related quality of life specific to patients with alcohol use disorder: the Alcohol Quality of Life Scale (AQoLS). Quality of Life Research, 25, 1549-1560.

o Simms, L. J. (2008). Classical and Modern Methods of Psychological Scale Construction. Social and Personality Psychology Compass, 2(1), 414–433. https://doi.org/10.1111/j.1751-9004.2007.00044.x

• I believe the effect of the sample and assessment time periods on validity associations needs to be discussed more in the manuscript. For example, in the discussion, it is stated that the low correlation between the number of HDD in the last 4 weeks and the AQoLS-brief suggests that drinking intensity has limitations as an outcome. While there is some truth to this statement, I think the association between the number of HDD in the last 4 weeks and the AQoLS-brief needs some more discussion. If I am understanding the inclusion criteria correctly, patients recently detoxified and, at minimum, did not drink in the last 7 days (up to 30). This means that heavy drinking for individuals was at minimum ¼ lower, and potentially completely absent, in the assessment period. Consequently, this inclusion criteria artificially attenuates the association between drinking intense and quality of life. In my opinion, and if I am understanding things correctly, this is likely the best explanation for why heavy drinking and quality of life from drinking were not significantly associated with one another. The conclusion above about this association should be tempered.

o The association with the CGI-severity score has a similar issue. It is concluded that assessing impairment in an inpatient setting does not capture the full spectrum of quality-of-life alcohol impairment. Again, I do not inherently disagree with this statement, but the past 7 days, by definition of the inclusion criteria, means that there was not alcohol use present during the time of the CGI-severity assessment. Would this not artificially decrease the disease severity score to be lower and thus attenuate the CGI-severity and AQoLS-brief association?

• I would like to hear more information about excluding patients currently experiencing withdrawal symptoms from the current analysis. What proportion of the sample does this exclude? Does this only include extreme, life-threatening withdrawal symptoms, or even more mild withdrawal symptoms? If it is life-threatening symptoms only then that makes sense for safety purposes. However, exclusion based on mild withdrawal symptoms may bias the sample unnecessarily.

• I am wondering why other item selection analyses were not used to guide item selection, such as item discrimination and item difficulty. Some rationale as to why these were not used would be helpful.

• This is a minor, but there are so many acronyms it is difficult to follow the manuscript at times. I recommend only using very common acronyms (e.g., AUD, DSM-5) and writing out most other acronyms.

• This is also minor, but please proofread the manuscript for correct grammar. For example, on lines 52-54, it reads: “However, its length could limit its use in clinical trials, where subjective measurements are not often the primary judgment outcome (Luquiens et al. 2012) and there is often numerous and time spending measures.” Instead of “there is often numerous and time spending measures,” I assume the authors mean, “there is often numerous and time intensive measures.” There are several places throughout the manuscript where the wording or grammar is slightly off.

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: PLOS ONE review_12.2024.docx

PONE-D-24-44639R1AQoLS-Brief: development and psychometric properties of a short version of the Alcohol Quality of Life ScalePLOS ONE

Dear Dr. Luquiens,

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 submit your revised manuscript by Apr 09 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'.
• 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,

Shivanand Kattimani

Academic Editor

PLOS ONE

Journal Requirements:

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: 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

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

Reviewer #1: Yes

Reviewer #2: 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: Yes

Reviewer #2: 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: 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: (No Response)

Reviewer #2: The authors have thoroughly responded to all my critiques. I commend the authors for their comprehensive and well-reasoned responses. The changes made have greatly strengthened the manuscript and increased the manuscripts contribution to the literature. I have one final minor comment to be addressed:

1. In the hypotheses (starting line 215), it would be helpful to specify the hypothesized directions of the associations (positive or negative) in addition to the strength of the correlations.

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Reviewer #1: No

Reviewer #2: No

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AQoLS-Brief: development and psychometric properties of a short version of the Alcohol Quality of Life Scale

PONE-D-24-44639R2

Dear Dr. Luquiens,

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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Shivanand Kattimani

Academic Editor

PLOS ONE

Reviewers' comments: