Suicidal ideation and interrelated psychiatric disturbances in rheumatoid arthritis: Evidence from a Vietnamese cohort

Ha Thi Thu Tran; Tam Minh Duong; Tuan Van Nguyen; Ha Thi Thu Le; Hue Thi Doan; Yen Hoang Nguyen; Hoa Thi Nguyen; Long Thanh Nguyen; Thang Xuan Pham; An Thi Ha Tran; Phi Van Nguyen; Son Truong Hoang; Thien Cong Le; Hung Van Nguyen

doi:10.1371/journal.pone.0342909

Peer Review History

Original SubmissionDecember 16, 2025
16 Dec 2025 Author Response Attachments Attachment Submitted filename: rasuicide_response letter.docx https://doi.org/10.1371/journal.pone.0342909.r001
20 Jan 2026 Decision Letter - Marwan Al-Nimer, Editor Dear Dr. Thi Thu Tran, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ============================== ACADEMIC EDITOR: Major Revision ============================== Please submit your revised manuscript by Mar 05 2026 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. A letter that responds to each point raised by the academic editor and reviewer(s). 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When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process. 3. We notice that your Figure S2 is uploaded with the file type 'Figure'. Please amend the file type to 'Supporting Information'. Please ensure that each Supporting Information file has a legend listed in the manuscript after the references list. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Additional Editor Comments: 1-Add the value of Cronbach's alpha 2- Type the references according to the PLoS ONE 3- Improve the quality of the figures [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: This manuscript addresses an important and underexplored topic: suicidal ideation among patients with rheumatoid arthritis. The study is generally well conducted, clearly written, and the revisions have substantially improved methodological transparency. From a psychiatric perspective, the manuscript is suitable for publication, with several points that could further strengthen conceptual clarity and clinical interpretation. Major comments Title clarity The term “mental health disturbances” in the title is relatively broad and nonspecific. Given that the study explicitly examines depression, anxiety, insomnia, sexual dysfunction, and suicidal ideation, the authors may consider revising the title to reflect these specific psychiatric domains more clearly. This would improve conceptual precision and better align the title with the actual content of the manuscript. Clarification of suicidal ideation assessment Suicidal ideation was assessed through structured psychiatric interviews, which is a strength. However, the manuscript treats suicidal ideation as a binary outcome without clarifying its clinical scope. Please briefly clarify whether suicidal ideation primarily reflected passive death wishes, active suicidal thoughts, or any planning or intent, and acknowledge in the Discussion that different forms of ideation carry different clinical implications. Conceptual overlap with depressive symptoms Because depressive symptom measures (e.g., PHQ-9) include suicidality-related content, some conceptual overlap between depression and suicidal ideation is unavoidable. Please add a brief acknowledgment of this issue and emphasize that suicidal ideation was assessed independently via clinician interview rather than self-report alone. Interpretation of large effect sizes Some odds ratios for suicidal ideation are large with wide confidence intervals due to the limited number of events. It would be helpful to further emphasize that these estimates should be interpreted as indicators of association rather than precise risk quantification. Minor comments Terminology Please clarify that suicidal ideation represents a marker of psychological distress and potential risk, but does not equate to suicide attempts or suicide mortality. Clinical implications The conclusion appropriately calls for integrated mental health screening. Adding one brief, concrete example (e.g., routine screening questions or referral pathways) may further enhance clinical relevance for non-psychiatric readers. Reviewer #2: Overall Assessment This is an excellent and timely study that is highly relevant to contemporary Primary Health Care. The manuscript is logically structured, demonstrating high standards of academic writing and a clear understanding of the subject matter. Section-by-Section Analysis Introduction: The theoretical framework is sound. It effectively contextualizes the research problem and establishes a compelling rationale for the study. Methodology: The research design is articulated with precision. The methodology is well-explained, providing sufficient detail for reproducibility and justifying the chosen approach. Discussion: The interpretation of the findings is generally well-executed, situating the results within the broader context of existing Primary Health Care research. Limitations: The authors have shown commendable reflexivity. The study limitations are explicitly "enlightened" and transparently discussed, which strengthens the integrity of the findings. ****** 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 #1: No Reviewer #2: Yes: Roland Mbuyi Tshibeya ******** [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.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. Attachments Attachment Submitted filename: rasuicide_manuscript.docx https://doi.org/10.1371/journal.pone.0342909.r002
Revision 1
26 Jan 2026 Author Response Responses to Comments Reviewer 1: Comment 1: The term “mental health disturbances” in the title is relatively broad and nonspecific. Given that the study explicitly examines depression, anxiety, insomnia, sexual dysfunction, and suicidal ideation, the authors may consider revising the title to reflect these specific psychiatric domains more clearly. This would improve conceptual precision and better align the title with the actual content of the manuscript. Response: We agree that the term “mental health disturbances” may be overly broad, and we have revised the title to more explicitly reflect the specific psychiatric domains examined in this study. The updated title improves conceptual clarity and better aligns with the manuscript’s content. Comment 2: Suicidal ideation was assessed through structured psychiatric interviews, which is a strength. However, the manuscript treats suicidal ideation as a binary outcome without clarifying its clinical scope. Please briefly clarify whether suicidal ideation primarily reflected passive death wishes, active suicidal thoughts, or any planning or intent, and acknowledge in the Discussion that different forms of ideation carry different clinical implications. Response: We would like to clarify that the clinical scope of suicidal ideation was explicitly defined in the Methods section (Study outcomes). Suicidal ideation was assessed through structured clinical interviews conducted by board-certified psychiatrists and encompassed the presence of suicidal thoughts, intent, or planning, in accordance with established psychiatric diagnostic guidelines. For the purposes of analysis, any report of suicidal thoughts—regardless of frequency or intensity—was classified as a positive outcome, and the variable was therefore treated as binary. We agree with the reviewer that dichotomizing suicidal ideation may obscure clinically meaningful distinctions between passive death wishes, active suicidal thoughts, and suicidal intent or planning, each of which carries different prognostic and clinical implications. Accordingly, we have added a statement in the Discussion acknowledging this limitation. Comment 3: Because depressive symptom measures (e.g., PHQ-9) include suicidality-related content, some conceptual overlap between depression and suicidal ideation is unavoidable. Please add a brief acknowledgment of this issue and emphasize that suicidal ideation was assessed independently via clinician interview rather than self-report alone. Response: We agree that some degree of overlap between depressive symptom measures and suicidal ideation is unavoidable. This point has now been explicitly acknowledged in the Discussion section, where we note the potential conceptual overlap while emphasizing that suicidal ideation in this study was assessed independently through clinician-administered structured interviews rather than self-report measures alone. Comment 4: Some odds ratios for suicidal ideation are large with wide confidence intervals due to the limited number of events. It would be helpful to further emphasize that these estimates should be interpreted as indicators of association rather than precise risk quantification. Response: We have revised the corresponding statement in the Discussion to further emphasize that the large odds ratios with wide confidence intervals should be interpreted as indicators of association rather than precise risk quantification, particularly given the limited number of suicidal ideation events. Comment 5: Please clarify that suicidal ideation represents a marker of psychological distress and potential risk, but does not equate to suicide attempts or suicide mortality. Response: We have added a statement in the Discussion to emphasize that suicidal ideation represents a marker of psychological distress and potential risk, but does not equate to suicide attempts or suicide mortality, and should be interpreted accordingly. Comment 6: The conclusion appropriately calls for integrated mental health screening. Adding one brief, concrete example (e.g., routine screening questions or referral pathways) may further enhance clinical relevance for non-psychiatric readers. Response: We have revised the Conclusion to include a brief, concrete example of how integrated mental health screening could be implemented in routine rheumatology practice, such as the use of brief screening questions during clinical visits and referral to mental health services when indicated, to enhance clinical relevance for non-psychiatric readers. Reviewer 2: This is an excellent and timely study that is highly relevant to contemporary Primary Health Care. The manuscript is logically structured, demonstrating high standards of academic writing and a clear understanding of the subject matter. Section-by-Section Analysis Introduction: The theoretical framework is sound. It effectively contextualizes the research problem and establishes a compelling rationale for the study. Methodology: The research design is articulated with precision. The methodology is well-explained, providing sufficient detail for reproducibility and justifying the chosen approach. Discussion: The interpretation of the findings is generally well-executed, situating the results within the broader context of existing Primary Health Care research. Limitations: The authors have shown commendable reflexivity. The study limitations are explicitly "enlightened" and transparently discussed, which strengthens the integrity of the findings. Response: We sincerely thank the reviewer for the positive and encouraging evaluation of our manuscript. We appreciate the recognition of the study’s relevance, methodological rigor, and clarity of presentation. We are also grateful for the reviewer’s acknowledgment of the theoretical framework, transparency in reporting, and the balanced discussion of limitations. Editorial comments: Comment 1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Response: We thank the editorial team for this reminder. We confirm that the manuscript has been prepared in accordance with PLOS ONE’s style and formatting requirements, including file naming conventions, and follows the official PLOS ONE templates for the main body as well as the title, authors, and affiliations. Comment 2: When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process. Response: We would like to confirm that all datasets generated and/or analysed during the current study have already been deposited in a public data repository and are freely accessible. The data are publicly available via the Harvard Dataverse at https://doi.org/10.7910/DVN/KCQKHM, in full compliance with PLOS ONE’s open data policy. Accordingly, no access restrictions apply, and no exemption is required. Comment 3: We notice that your Figure S2 is uploaded with the file type 'Figure'. Please amend the file type to 'Supporting Information'. Please ensure that each Supporting Information file has a legend listed in the manuscript after the references list. Response: We have amended the file type of Figure S2 to Supporting Information and ensured that the corresponding legend is listed in the manuscript after the references, in accordance with PLOS ONE guidelines. Comment 4: Add the value of Cronbach's alpha Response: We would like to clarify that the Cronbach’s alpha values for all psychometric scales used in the study have already been fully reported in the Supporting Information (Table S1: Preliminary validation metrics of psychometric scales in the study cohort). This table provides Cronbach’s alpha coefficients for PHQ-9, HAM-A, ISI, ASEX, and EQ-5D-5L, along with additional reliability and validity indicators. Comment 5: Type the references according to the PLoS ONE Response: We would like to confirm that all references in the manuscript have been formatted in accordance with the PLOS ONE reference style guidelines. Comment 6: Improve the quality of the figures Response: We confirm that all figures have been prepared and uploaded in accordance with PLOS ONE’s technical requirements, including resolution, format, and overall figure quality. Attachments Attachment Submitted filename: rasuicide_response_letter_auresp_1.docx https://doi.org/10.1371/journal.pone.0342909.r003
30 Jan 2026 Decision Letter - Marwan Al-Nimer, Editor SUICIDAL IDEATION, MENTAL HEALTH DISTURBANCES, AND QUALITY OF LIFE IN RHEUMATOID ARTHRITIS: EVIDENCE FROM A VIETNAMESE COHORT PONE-D-25-66452R1 Ha Thi Thu Tran Dear Dr. Ha Thi Thu Tran, 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. For questions related to billing, please contact billing support . 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, Marwan Salih Al-Nimer, MD, PhD Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0342909.r004
Formally Accepted
Acceptance Letter - Marwan Al-Nimer, Editor PONE-D-25-66452R1 PLOS One Dear Dr. Tran, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Professor Marwan Salih Al-Nimer Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0342909.r005

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