PONE-D-24-39274Differential Cognitive and Clinical Improvements in Schizophrenia and Bipolar Disorder Following Hospitalization: A Comparative Analysis Based on the Clock Drawing TestPLOS ONE

Dear Dr. Mirfazeli,

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.

==============================This holds an interesting potential to the field and I read with enthusiasm. Nevertheless, there are several concerns from definitions to proper interpretation of the findings. I will list as follows:

1) Please double-check grammar (e.g. punctuation and verb tense);

2) Please double-check refs (e.g. formatting and punctuation);

3) The use of convenience sampling without justification introduces selection bias and limits generasalitions. Also, the absence of controls further weakens the findings. It'd be interesting a more representative sampling method or refining the existing approaches. For instance, the sample size is vague, relying on an effect size from a prior study without clear assumptions or a power analysis. The explanation of its selection, the effects selection and the CIs are essential. The lack of details on inter-rater reliability introduces risks to data accuracy. Overall, both Methods and Results need to be considerably reshaped to ensure a rigorous and transparent study. Also, consider that 1. There is no mention of controlling for medication, comorbidities, or treatment duration, which influence the observed differences, 2. Values are provided without effect sizes or CIs, making the results harder to interpret, 3. There is an inconsistency in how SDs are reported as well as decimals, 4. The tables lack clear labelling, making it difficult to interpret results, and there aren't graphs to visually represent the data. Please consider refining those too;

4) Results:

- Admission

The intriguing difference between symptom burden in patients aligns with clinical understanding. The interesting thing is the less proeminence within a group with several differences in meds, especially poly use of meds. These comparable outcomes in test kind indicate the notion that there are impairments regardless of the condition, albeit through potentially different mechanisms. However, although important, both tests won't provide a bigger picture to subtle differences in functional outcomes. Comparable global severity and cognitive impairments in both groups highlight the importance of addressing functional outcomes across groups. To strengthen this section, the authors could consider including merged symptom indices, interaction, any possible influence of PANSS, pos and negative, across the tests, etc;

- Discharge

- Trends in PANSS negative symptoms and scores hint subtle differences that might warrant investigation with larger sample sizes. As mentioned, understanding the correlations and interactions of the discharge measurements would be really interesting to have a comprehension of the gap or what could have occurred to explain the differences. Examining predictors, correlating changes, and subgroup analyses provide more detailed insights into the findings;

- The paired tests should be better explored to explain the main clinical implications of the data. Link specific meds to outcomes (e.g. PANSS scores, CGI changes) to evaluate the efficacy of different treatments in each group - even subtle;

- Overall, PANSS differences at admission predict scores at discharge, with negative symptoms showing stronger consistency. This is important, although completely different from changes in CGI, for example, where the pos symptoms were contundent;

5) I calculated and noticed that differences were closely linked to baseline severity. Higher baseline positive symptoms strongly predicted changes in positive symptoms (R² = 0.639, p < 0.001), while cognitive had minimal influence. This was interesting in CGI when baseline negative symptoms were higher (interaction p = 0.019). Patients starting with more severe positive symptoms had improvements, which is counterintuitive. For instance, for delta PANSS the differences were really worth investigating. The meds also influenced the outcomes. While running PCA,  I observed that 91.6% of the variance in PANSS items was explained by three components, with PC1 (48.3%) likely reflecting overall symptom severity. PC1 correlated with changes in positive symptoms and global severity. This is aligning with observed data a few years ago, but the lack of logical explanation between PANSS and other variables with the fluctuation in scores are worrying. Please expand and improve the Results and Discussion;

6) Overall, without proper refinement it's difficult to assess the relevance of the study;

Thank you for your valuable submission.

Wishing you success with the study.

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

Please submit your revised manuscript by Feb 26 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Thiago P. Fernandes, PhD

Academic Editor

PLOS ONE

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2. Please describe in your methods section how capacity to provide consent was determined for the participants in this study. Please also state whether your ethics committee or IRB approved this consent procedure. If you did not assess capacity to consent please briefly outline why this was not necessary in this case.

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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: Partly

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: Yes

**********

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

**********

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

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The study, "Differential Cognitive and Clinical Improvements in Schizophrenia and Bipolar Disorder Following Hospitalization: A Comparative Analysis Based on the Clock Drawing Test" by Ahmad Pirani et al., examined changes in cognitive function among hospitalized patients with Schizophrenia and Bipolar Disorder with Psychotic Features (BDP) using the Clock Drawing Test (CDT). This study included 84 patients, equally divided between those with Schizophrenia and those with BDP. Patients were evaluated at hospital admission and discharge using the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression (CGI). The results indicated that patients with Schizophrenia showed very little improvement in cognitive function after treatment compared to those with BDP, suggesting a potential inherent cognitive deficit associated with Schizophrenia. However, the study lacks information about the treatment or medications provided, and the small sample size limits the strength of its conclusions. Moreover, the study design was not sufficiently robust to fully address the stated hypothesis. The authors also did not assess other critical cognitive domains, such as attention, memory, reasoning, and executive functions. Overall, while the findings are suggestive, additional research with more comprehensive methodologies and larger samples is needed.

Reviewer #2: Dear Editor,

I appreciate the opportunity to review the manuscript entitled:

"Differential Cognitive and Clinical Improvements in Schizophrenia and Bipolar Disorder Following Hospitalization: A Comparative Analysis Based on the Clock Drawing Test"

I commend the authors for describing this critical and timely issue. The paper is interesting and well-written; however, I would like to highlight some issues that merit revision:

In the manuscript, it is not detectable whether an assessment was made of what might be a protective factor through psychotherapy and counseling intervention, which people often use without prescription to prevent or alleviate symptoms at the onset. I would ask the authors if this was evaluated during the survey and add a short paragraph on this issue; if data are unavailable, add them to the limitations.

**********

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: No

Reviewer #2: No

**********

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Attachments

Attachment

Submitted filename: illustration-eg.pdf

PONE-D-24-39274R1Differential Cognitive and Clinical Improvements in Schizophrenia and Bipolar Disorder Following Hospitalization: A Comparative Analysis Based on the Clock Drawing TestPLOS ONE

Dear Dr. Mirfazeli,

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.

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

Thank you for your valuable submission.

This is indeed a good and interesting study.

I encourage the authors to carefully review all comments, and ensure that the rebuttal clearly outlines both the changes made and any aspects that remain unchanged, with detailed justifications. Please bear in mind that our aim is to avoid an overly lengthy process, and we cannot guarantee further rounds if the revisions do not adequately address the reviewers’ concerns.

If the authors are willing to proceed, I would be happy to re-read and continue with.

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

Please submit your revised manuscript by May 05 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,

Thiago P. Fernandes, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

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

Reviewer #3: (No Response)

**********

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: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

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: Yes

Reviewer #3: Yes

**********

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

Reviewer #3: Yes

**********

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 paper is very interesting and well-written, methodologically unexceptionable, and the new implementations provide a valid contribution to the work. Every requested correction has been done, and the manuscript is now suitable for publication.

Reviewer #3: It is also uploaded and attached.

Thank you for the opportunity to review the manuscript, "Differential Cognitive and Clinical Improvements in Schizophrenia and Bipolar Disorder Following Hospitalization: A Comparative Analysis Based on the Clock Drawing Test," for PLOS One.

The purpose of this study was to examine changes in cognitive function and associated positive and negative symptoms among participants with schizophrenia and bipolar disorder with psychotic features (BDP). This study was cross-sectional and included 84 participants who were hospitalized at two psychiatric hospitals; participants were equally divided between both groups. Participants were evaluated at two timepoints (hospital admission and discharge) using the Positive and Negative Syndrome Scale (PANSS), the Clinical Global Impression (CGI), and the Clock Drawing Test (CDT). Within- and between- group changes on the outcome variables were assessed. The results indicated that participants with schizophrenia evidenced less improvement in cognitive function at post-treatment compared to participants with BDP, regardless of change in positive and negative symptoms but related to baseline cognitive profile. Findings suggest underlying cognitive deficits associated with schizophrenia.

I appreciate the focus of this study—as it appears that research examining cognitive functioning in bipolar disorder is limited. The manuscript is written clearly and the preliminary findings from this study have the potential for scientific contributions, which may later inform future research and clinical care. The manuscript may be further strengthened by the following comments and suggestions. As such, I am recommending that the following areas be addressed before the manuscript is considered for publication in PLOS One.

General

1. Please check that the manuscript is in accordance to APA style 7th Edition (e.g., spell out all acronyms, report p values less than .001 as “p < .001,” etc.)

2. Please be mindful of consistency in formatting (e.g., the first letters of “clock drawing test” are capitalized in some places in lowercase in other places, etc.)

Abstract

1. It might be helpful for the abstract to include information about participant demographics (e.g., age, race/ethnicity, gender) and to note the statistical methods employed.

2. Consider tempering language/conclusions since the study is examining associations among outcome variables. This is particularly important because the Clock Drawing Test is typically used as a screener for cognitive impairment in participants with schizophrenia. From this one score, I would use caution in concluding that less pronounced improvements on one cognitive screening measure suggest underlying cognitive deficits for participants with schizophrenia.

Introduction

1. Overall, the introduction is easy to read and well written. I appreciate the general literature review and that the authors acknowledged gaps in the literature and provided rationale for how the study addresses those gaps.

2. One of the aims of this study is to measure cognitive and clinical improvements after treatment. Although briefly addressed in the Discussion, the Introduction does not review relevant treatments and expected treatment response/clinical outcomes for these disorders, especially with regard to the study’s primary outcomes (i.e., positive/negative symptoms, cognition). Inclusion of this background information would provide a better context for the study results and would facilitate a discussion of potential clinical applications of study results in the Discussion.

3. Please clearly state study hypotheses and predictions that accompany study objectives.

Method

1. The timeframe that these data were collected is September 2021 to December 2022. Given that some data were collected during COVID-19, I’m wondering how the historical context may or may not affect study results (e.g., potentially exacerbate disease symptoms).

2. The credentials of the people making the schizophrenia and BDP diagnoses and how the diagnoses were made (e.g., comprehensive evaluation? diagnostic clinical interviewing? by history?) to determine if a participant met diagnostic criteria are not clear.

3. Participants were assessed at two timepoints (admission and discharge); however, it is not clear how many days participants were hospitalized during that timeframe. It would be helpful to include the average time (and SD) from admission to discharge for each group. I’m wondering if duration of hospital stay could be a factor influencing study results.

4. Authors state that all participants received occupational therapy. How often/how much OT did participants receive? I’m wondering if OT intervention duration plays a role in disorder symptoms and cognitive outcomes.

5. It was reported that participants received different biological treatments (i.e., medication and ECT). However, it is unclear how many participants received medication, ECT, or both treatments. What proportion of participants received medication, ECT, or a combination that could alter the frequency/severity of their symptoms and level of cognitive functioning?

6. Of the participants taking medication, how many were on medication for pre- and post-testing? Perhaps medication type positively or negatively affects CDT test performance and scores on the other measures.

7. The authors report demographic data for participant age and gender, but no additional demographic data is provided (i.e., race/ethnicity, primary language, comorbidity, SES, etc.). It is unclear if groups differ on these additional pre-treatment variables; not providing these data notably limit interpretation and generalizability of study results.

8. Relatedly, the demographic data for the total sample is provided in Table 1 but it is not provided for each group. Table 1 could be enhanced by reporting demographic data for both samples. Please see an example below:

Variable Schizophrenia

(n=42) BDP

(n=42) 95% CI Effect size p

M SD M SD

Gender (male/female) 51/33 / --

Age

Race/ethnicity (W/B/H/M) --

SES

Biological treatment status

Medication (No/Yes) --

ECT (No/Yes) --

Combination (No/Yes) --

Duration of OT (minutes)

Comorbidity (No/Yes) --

Duration of hospital stay (days)

9. I appreciate the detailed information about the instruments used in this study. Please also include the range of possible scores for each measure as well as instrument psychometrics (i.e., evidence for reliability, internal and external validity).

10. Were there any outliers? If so, how were those defined and handled?

11. The authors reported comparing the mean changes in each test score (discharge vs. admission) between the two groups. I'm curious if the authors considered using pre-treatment scores as a covariate, especially since schizophrenia participants had significantly higher baseline PANSS-negative scores, to test whether post-treatment means, adjusted for pre-treatment scores, differed between the two groups.

12. This may be beyond the scope of the study, but I'm curious as to what a mixed-model ANOVA (group x symptom domain [positive, negative, cognitive, CDT] x time) would yield with regard to the interaction terms.

Results

1. Table 2 does not clearly show the data in an organized manner, and it is difficult to follow. Consider the following table:

Variable Schizophrenia

(n=42) BDP

(n=42) 95% CI Effect size p

M SD M SD

Pre-treatment/Admission

CDT

PANNS Positive

PANNS Negative

Post-treatment/Discharge

CDT

PANNS Positive

PANNS Negative

2. The severity of positive psychotic symptoms was found to be similar across both groups. Could this be a result of sampling bias (positive symptoms are likely more noticeable/impairing than negative symptoms, prompting hospitalization at a psychiatric facility)?

Discussion

1. I appreciate that the authors provide rationale and evidence from literature to explain why there were more pronounced improvements in cognitive function at post-treatment for the BDP group than for the schizophrenia group. However, the authors do not address the potential effects of biological treatment and intervention (i.e., OT) on these outcomes. Perhaps the authors could comment on treatment/intervention factors that might influence primary outcomes, using previous literature on expected treatment response/clinical outcomes for these disorders in the explanation.

2. I appreciate that the authors provide an implication for clinical practice. However, the implication seems relatively general and to lack clear, detailed guidelines for actionable steps, which limits the applicability of findings for researchers and practitioners. It would be helpful to expand this implication and to provide guidance for researchers and practitioners to follow. For example, earlier in the manuscript the authors mention cognitive intervention as a potential effective treatment for these disorders, but it was not further addressed in the Discussion as a potential future direction for the field.

3. In terms of the limitations, I appreciate that the authors acknowledge that the study’s relatively small sample size is a limitation. However, the authors do not address that the majority of study participants identify as male, which also limits generalizability. I find myself looking to the context to help explain why the sample mostly identifies as male, but little context is provided.

4. Perhaps authors could comment on potential sampling bias and limits to generalizability with regard to collecting data during COVID-19 and to collecting data from study participants who were hospitalized. Another potential limitation may be that the study lacked a control group.

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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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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

[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.

Attachments

Attachment

Submitted filename: PLOS one Review 2025.docx

<p>Differential Cognitive and Clinical Improvements in Schizophrenia and Bipolar Disorder Following Hospitalization: A Comparative Analysis Based on the Clock Drawing Test

PONE-D-24-39274R2

Dear Dr. Mirfazeli,

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,

Thiago P. Fernandes, PhD

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 #3: All comments have been addressed

**********

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

**********

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

Reviewer #3: Yes

**********

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: Yes

**********

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

**********

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 really appreciate the authors' effort and care in addressing all of the reviewer comments. Thank you for the thoroughly re-working sections of the manuscript and for explaining the study data collection process and for full transparency in what data were and were not collected. The only thing that I can think of that may strengthen the study is to add a power analysis (converting F values to Cohen's d) to investigate if the study sample is sufficiently powered to detect within- and between-subject effects.

**********

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 #3: No

**********