Impact of the COVID-19 Pandemic on Adolescent Self-Harm: Based on a National Emergency Department Information System
Round 1
Reviewer 1 Report
A relevant overview of the paper is presented in the abstract. It is included the antecedents, the purpose of the study, the methods, the summary of main findings and the conclusions. I also perceive an objective representation of the article.
The introduction is developed in a broad context, highlighting the importance of the topic and defining the purpose of the paper and its meaning. Thus, the current state of the research field has been reviewed, including adequate and sufficient citations. References are made to various studies focused on the topic at a general level and specifically in Korea, where it seems that the fundamental publications are cited.
Some controversial hypothesis is indicated, which can be verified. The main objective of the paper is indicated in relation to the comparison and analysis of self-harm trends before and after the Covid-19 pandemic.
Main conclusions are raised. The introduction is understandable. References are appropriately numbered in order of appearance.
Regarding the proposed study method, they are described in some detail, which will facilitate the replication of the results. As it is a public database (NEDIS) composed of a large set of data available to the public, it is convenient to specify the protocols followed associated with its consultation and publication and refer to their reliability.
The statistical instruments that have been used for the analysis of the study are indicated. Some kind of data gap is noted in the NEDIS database, but does not refer to restrictions on the availability of certain public data. Exclusion criteria were established for the data between 2016 and 2018 due to the drastic increase in self-harm and suicides.
Although the data is public, the study involves people, mostly minors linked to healthcare, who may require ethical approval indicating the authority that approves the data and its reliability and validity for the study.
This section is appropriately divided into subheadings, favouring an adequate description of the results that are analysed, highlighting in the comparison of patients who visited an emergency department for self-harm in Korea (Table 1), the time of year, the population, the vehicle, sex, age, type of injury, hospitalization rate, etc. In the comparison between before and after Covid (Table 2), the differences by age groups, times of the year, type of injury, visit to the emergency room and hospitalization are pertinently specified.
The discussion is the point of the study that offers more development and contribution of results that must be interpreted and contrasted in perspective with other previous studies. However, all the results of the study appear and are not always discussed with other data from related reports or studies.
It is indicated that the study is the first to compare adolescent self-harm before and after COVID-19 by analysing the data provided by NEDIS, in relation to demographic changes in Korea and the impact of the Covid 19 pandemic.
The hypothesis regarding the contradictory research results attributed to the difference in data research methods is not sufficiently discussed or verified.
The findings and their implications are discussed in a broader context, highlighting the strengths around demographic changes, the number of patients visiting the emergency room, gender, seasons of the year, methods used, before and after, etc However, it is recommended to incorporate some more study or report to compare and discuss the results that are offered.
The limitations of the study and future research directions that can be taken in the future are specified, such as the identification of the causes of these results to prevent self-harm among adolescents.
The conclusions added to the article clearly and precisely summarize what was provided in a sufficiently broad discussion.
Author Response
Response to Reviewer Comments
Point 1 : A relevant overview of the paper is presented in the abstract. It is included the antecedents, the purpose of the study, the methods, the summary of main findings and the conclusions. I also perceive an objective representation of the article.
The introduction is developed in a broad context, highlighting the importance of the topic and defining the purpose of the paper and its meaning. Thus, the current state of the research field has been reviewed, including adequate and sufficient citations. References are made to various studies focused on the topic at a general level and specifically in Korea, where it seems that the fundamental publications are cited.
Some controversial hypothesis is indicated, which can be verified. The main objective of the paper is indicated in relation to the comparison and analysis of self-harm trends before and after the Covid-19 pandemic.
Response 1 : Thank you for your encouraging words and thoughtful comments. We have added following content to verify the hypothesis you deemed controversial.
The former research [9] was conducted using national data, as did the current study, whereas the latter study [13] analyzed single-center data. Such a large variation might be attributed to the use of a single center design
Point 2 : Main conclusions are raised. The introduction is understandable. References are appropriately numbered in order of appearance.
Regarding the proposed study method, they are described in some detail, which will facilitate the replication of the results. As it is a public database (NEDIS) composed of a large set of data available to the public, it is convenient to specify the protocols followed associated with its consultation and publication and refer to their reliability.
Response 2 : Thank you for your suggestion. The relevant content has been added to the data availability statement as follows.
Data can be obtained by submitting the documents required by the National Emergency Medical Center, including a research plan and IRB approval-related documents, undergoing the review process, and then paying a fee.
Point 3 : The statistical instruments that have been used for the analysis of the study are indicated. Some kind of data gap is noted in the NEDIS database, but does not refer to restrictions on the availability of certain public data. Exclusion criteria were established for the data between 2016 and 2018 due to the drastic increase in self-harm and suicides.
Response 3 : Thank you for your suggestion. The limitation in the discussion section has been revised as to mention the limitation of the available data.
This study has a few limitations. The first is the limitation of the data provided
Point 4: Although the data is public, the study involves people, mostly minors linked to healthcare, who may require ethical approval indicating the authority that approves the data and its reliability and validity for the study.
Response 4: : Thank you for your suggestion. The participants of this study included vulnerable populations. Therefore, we drafted protective measures for vulnerable groups per the IRB SOP at the time of IRB submission, which the IRB then approved. This study was approved by the IRB of Daegu Catholic University Hospital (IRB number: CR-22-035-L). Informed consent was not required.
Point 5 : This section is appropriately divided into subheadings, favouring an adequate description of the results that are analysed, highlighting in the comparison of patients who visited an emergency department for self-harm in Korea (Table 1), the time of year, the population, the vehicle, sex, age, type of injury, hospitalization rate, etc. In the comparison between before and after Covid (Table 2), the differences by age groups, times of the year, type of injury, visit to the emergency room and hospitalization are pertinently specified.
The discussion is the point of the study that offers more development and contribution of results that must be interpreted and contrasted in perspective with other previous studies. However, all the results of the study appear and are not always discussed with other data from related reports or studies.
It is indicated that the study is the first to compare adolescent self-harm before and after COVID-19 by analysing the data provided by NEDIS, in relation to demographic changes in Korea and the impact of the Covid 19 pandemic.
The hypothesis regarding the contradictory research results attributed to the difference in data research methods is not sufficiently discussed or verified.
The findings and their implications are discussed in a broader context, highlighting the strengths around demographic changes, the number of patients visiting the emergency room, gender, seasons of the year, methods used, before and after, etc However, it is recommended to incorporate some more study or report to compare and discuss the results that are offered.
Response 5 : Thank you for your encouraging words and thoughtful comments. I have incorporated additional references into the discussion section and implemented overall revisions to enhance the content.
Point 6 : The limitations of the study and future research directions that can be taken in the future are specified, such as the identification of the causes of these results to prevent self-harm among adolescents.
The conclusions added to the article clearly and precisely summarize what was provided in a sufficiently broad discussion.
Response 6 : Thank you for your encouraging words and thoughtful comments.
Author Response File: 
Author Response.doc
Reviewer 2 Report
The authors performed a solid analysis and it is an innovative study in a relevant topic. The authors provide relevant research data and conclusions. The Abstract is concise and summarizes the article content. The Introduction represents an adequate synthesis of the literature. The results match the summary of results presented in the abstract and align with the aim. Data is presented in an appropriate way, table and figures are relevant and clearly presented.
Weakness of the article is discussion. Whilst the review of the work to date is well presented, the article does not contain much current world data collected. This needs re-working as the discussion traditionally begins with restating the aim of the study and then a summary of how the findings addressed the aims.
Unfortunately there is also a clear lack of discussion about how the findings from this study compare or contrast with the global results
The latter is obviously very important from a public health perspective (and thus to the aims and scope of the journal). Attention to these details will improve the manuscript considerably.
Some suggestions that might be included:
ZHU, H., et al. Comparisons of different classification algorithms while using text mining to screen psychiatric inpatients with suicidal behaviors. Journal of psychiatric research, 2020, 124: 123-130.
https://doi.org/10.1192/bjp.2022.79
https://doi.org/10.3390/ijerph16152806
https://doi.org/10.1007/s00787-022-02039-x
Line 187: Please, replace "committed" by "died by suicide"
Author Response
Response to Reviewer Comments
Point 1 : The authors performed a solid analysis and it is an innovative study in a relevant topic. The authors provide relevant research data and conclusions. The Abstract is concise and summarizes the article content. The Introduction represents an adequate synthesis of the literature. The results match the summary of results presented in the abstract and align with the aim. Data is presented in an appropriate way, table and figures are relevant and clearly presented.
Response 1 : Thank you for your insightful comments.
Point 2 : Weakness of the article is discussion. Whilst the review of the work to date is well presented, the article does not contain much current world data collected. This needs re-working as the discussion traditionally begins with restating the aim of the study and then a summary of how the findings addressed the aims.
Unfortunately there is also a clear lack of discussion about how the findings from this study compare or contrast with the global results
The latter is obviously very important from a public health perspective (and thus to the aims and scope of the journal). Attention to these details will improve the manuscript considerably.
Some suggestions that might be included:
ZHU, H., et al. Comparisons of different classification algorithms while using text mining to screen psychiatric inpatients with suicidal behaviors. Journal of psychiatric research, 2020, 124: 123-130.
https://doi.org/10.1192/bjp.2022.79
https://doi.org/10.3390/ijerph16152806
https://doi.org/10.1007/s00787-022-02039-x
Response 2 : Thank you for your constructive advice and sound suggestions. We have revised the parts you mentioned. I have incorporated additional references into the discussion section and implemented overall revisions to enhance the content.
Point 3 : . Line 187: Please, replace "committed" by "died by suicide"
Response 3 : According to your suggestion, I have revised the text as follows : “most died by suicides in spring”.
Author Response File: Author Response.doc
Reviewer 3 Report
This manuscript aimed to assess the changes in adolescent patients who visited the emergency department after inflicting self-harm over the past five years and compare self-harm prevalence before and after the COVID-19 pandemic in Korea. The analysis of the impact of the COVID-19 pandemic on adolescent mental health is important for public health science and practice.
There are my comments:
Ethical considerations are missing.
Korean Triage and Acuity Scale should be presented in more detail, including referencing. On what basis was decided to indicate the severity of the emergency in points in particular ranges (1-3 and 4-5 points)?
The number of visits per 100,000 population was analysed, however, in Tables we see „visits per day“. Please clarify it and revise the Methods section clearly explaining the variables in Tables.
The statistics section should be expanded and referenced. Norms for tests should be provided following referencing.
Table 1 is confusing. It is difficult to understand what is „Male“ and what is „Per day“ in the second line. Please explain it in Methods or revise it. What p-value means in Table 1? Which variables or groups are significantly different? The same is for Table 2. Please clearly explain in text what groups were compared and what exactly was significantly different. Please also revise Tables.
Please revise the statistics, descriptions of the results and Tables. Notes right after the tables should be presented including an explanation of symbols used in Tables.
Author Response
Response to Reviewer Comments
Point 1 : Ethical consideration are missing.
Response 1 : This study was conducted with a population that included the vulnerable. Therefore, we drafted protective measures for vulnerable groups in accordance with the IRB SOP at the time of IRB submission, which was approved by IRB. This study was approved by the IRB of Daegu Catholic University Hospital (IRB number: CR-22-035-L). Informed consent was not required.
Point 2 : . Korean Triage and Acuity Scale should be presented in more detail, including referencing. On what basis was decided to indicate the severity of the emergency in points in particular ranges (1-3 and 4-5 points)?
Response 2 : The Korean Triage and Acuity Scale is an emergency patient classification system enforced by the laws of the Republic of Korea, and the details are published by the Ministry of Health and Welfare. According to the notice, those with scores 1 to 3 are classified as severely ill or suspected severely ill emergency patients, and those with scores 4 and 5 are classified as mild emergency and non-emergency patients, respectively. The Ministry of Health and Welfare notice is added as a reference.
Point 3 : The number of visits per 100,000 population was analysed, however, in Tables we see „visits per day“. Please clarify it and revise the Methods section clearly explaining the variables in Tables.
The statistics section should be expanded and referenced. Norms for tests should be provided following referencing.
Table 1 is confusing. It is difficult to understand what is „Male“ and what is „Per day“ in the second line. Please explain it in Methods or revise it. What p-value means in Table 1? Which variables or groups are significantly different? The same is for Table 2. Please clearly explain in text what groups were compared and what exactly was significantly different. Please also revise Tables.
Please revise the statistics, descriptions of the results and Tables. Notes right after the tables should be presented including an explanation of symbols used in Tables
Response 3 : Thank you for your constructive advice and sound suggestions. We have revised the parts you mentioned. We have endeavored to enhance the comprehensibility of the table by comprehensive modification.
Point 4 : The statistics section should be expanded and referenced. Norms for tests should be provided following referencing.
Response 4 : Thank you for your constructive advice and sound suggestions. We have revised the parts you mentioned. We have implanted the following modifications to the statistics section.
“Summary of the population characteristics using descriptive analysis. We obtained the values of mean and standard deviation (SD) for quantitative variables and the values of frequency and percent for qualitative variables. For the normality test, we used the Shapiro–Wilk test for continuous variables. To compare patients who visited the emergency room after self-harming by year, we performed one-way ANOVA or Friedman test according to whether the normality was satisfied for quantitative variables, and the chi-squared test for qualitative variables. For the com-parison before and after the start of the COVID-19 pandemic according to sex and age, we conducted two sample t-test or Mann–Whitney U test for quantitative variables depending on whether normality was satisfied, and a chi-squared test for qualitative variables. All p-values less than 0.05 were considered statistically significant. All tests were performed as a two-tailed test. We performed statistical analyses using IBM SPSS Statistics for Windows, version 21.0 (SPSS Inc., Chicago, IL, USA).”
Author Response File: Author Response.doc
Round 2
Reviewer 3 Report
Authors addressed my comments, however, ethical considerations are still missing in manuscript. Please insert the sentence in manuscript: "This study was approved by the IRB of Daegu Catholic University Hospital (IRB number: CR-22-035-L). Informed consent was not required".
Author Response
Response to Reviewer Comments
Point 1 : Authors addressed my comments, however, ethical considerations are still missing in manuscript. Please insert the sentence in manuscript: "This study was approved by the IRB of Daegu Catholic University Hospital (IRB number: CR-22-035-L). Informed consent was not required".
Response 1 : Thank you for your sound suggestions. We have revised the parts you mentioned. We have implanted the following modifications to the end of 2.2 study methods section.
We collected the following: patients’ age, sex, visit date, visit time, region, method of self-harm attempt (one choice), transportation, Korean Triage and Acuity Scale (KTAS) score, hospitalization, inpatient ward, emergency department (ED) exit time, discharge date, discharge time, and treatment results. By age, the patients were grouped into 10–14 and 15–19 years, in accordance with the regulations of the National Emergency Medical Center in Korea. Visit dates were classified by season, and regions were divided into metropolitan and non-metropolitan. As for transportation to visit the ED, we divided it into 119 ambulance, other ambulance, other vehicle, on foot, and unknown. The KTAS is scored by health care professionals on a scale of 1–5 depending on severity by comprehensively evaluating the main symptom, injury mechanism, pain level, general condition, and vital signs. The lower the score, the more severe the condition. In accordance with the emergency and non-emergency classification method of the Ministry of Health and Welfare [23], we classified scores 1 to 3 as “emergency” and scores 4 to 5 as “non-emergency.” Methods of self-harm attempt were classified into ingestion, cutting/stabbing, drowning, asphyxia/hanging, fall, and others. Final outcome was classified into survival, death, and unknown. Based on the collected data, we analyzed the number of ED visits per 100,000 population according to the population by year, age group, sex, and region provided by Statistics Korea, Korea’s central government organization for statistics. This study was approved by the Institutional Review Board of Daegu Catholic University Hospital (IRB number: CR-22-035-L). Informed consent was not required.
