The Mental Health State of Canadian Ophthalmologists during the COVID-19 Pandemic: A Survey-Based Study and Review
Round 1
Reviewer 1 Report
This paper demonstrated that a high proportion of ophthalmologist in Canada displayed psychological difficulties during the COVID-19 pandemic. The mental consequences of pandemic exposure were multi-faceted and affected many areas of functioning.
Overall, the paper is methodologically sound, and the results are in the expected direction.
I have a few questions and remarks:
- Please emphasize why this study is interesting and why it is appropriate to selectively investigate one medical speciality without a comparison with others.
- Was there any attempt to validate the questionnaire findings with a focus group? Although the study included a large number of participants, heterogeneity within this population cannot be excluded based on the data.
- Please delineate your hypotheses. What kind of results did you expect, and what was novel in the findings?
- Is the age-distribution of the participants representative? I noted a relatively small variance.
- The abstract should summarize the main conclusions of the paper.
Author Response
Comments and Suggestions for Authors
Comment 1: This paper demonstrated that a high proportion of ophthalmologist in Canada displayed psychological difficulties during the COVID-19 pandemic. The mental consequences of pandemic exposure were multi-faceted and affected many areas of functioning. Overall, the paper is methodologically sound, and the results are in the expected direction.
Answer 1: We wish to thank the reviewer for their appreciation of our article and their input to improving it.
I have a few questions and remarks:
Comment 2: Please emphasize why this study is interesting and why it is appropriate to selectively investigate one medical specialty without a comparison with others.
Answer 2: In response to this comment and to comments of Reviewer #2, the introduction has been significantly reworked to better elaborate on the interest of this study. As described below, the intimate proximity required to examine the eye stimulated our desire to focus on ophthalmologists. Comparing them to other medical specialties would have been interesting but was beyond the scope of our funding and expertise. With the methodology of the study, the group of interest that could be most easily approached remained members of the Canadian Ophthalmological Society. As such, the goal was rather to compare national data on Canadian ophthalmologists during the pandemic to similar studies performed in other countries.
Modifications 2:
INTRODUCTION
“This situation places ophthalmologists in a precarious position to continue offering care to patients at the risk of their own health and that of their loved ones. This has had an important impact on the mental health of ophthalmologists in various settings and countries, leading to significant depression, anxiety, stress, and insomnia in one third to two thirds of ophthalmologists abroad [3–8].
These changes can lead to further uncertainty and novelty which can affect the mental health of ophthalmologists.
We therefore sought to draw an overview of the state of mental health among ophthalmologists in Canada during the pandemic to provide national data to inform, destigmatize, and guide future interventions.”
Comment 3: Was there any attempt to validate the questionnaire findings with a focus group? Although the study included a large number of participants, heterogeneity within this population cannot be excluded based on the data.
Answer 3: In our experience, a focus group is sometimes done before the survey in order to determine what to ask about in the survey. However, we decided a priori based on our experience and previous literature to focus on 4 areas of mental health: depression, anxiety, insomnia, and post-traumatic stress. All four of the questionnaires that we used were previously validated, as described in the methods. We did not consider conducting a focus group after the survey, and are not sure this would have been well-received, give the sensitive nature of these questions and the stigma that sometimes comes with mental health issues.
Comment 4: Please delineate your hypotheses. What kind of results did you expect, and what was novel in the findings?
Answer 4: As answered above for Comment 2, the introduction was reworked to better reflect our hypotheses. The novelty of the findings is that this provides national data assessing the mental health of Canadian ophthalmologists which could be compared to that of other countries which were similar after all. This was elaborated in the discussion.
Modifications 4:
INTRODUCTION
“We expected to find higher rates of anxiety, depression, stress, and insomnia among ophthalmologists in similar proportions to other countries, though this could be partially mitigated by robust infection control measures which decreased the relative number of cases nationally.”
DISCUSSION
“This is very concerning but provides national data regarding the mental health of Canadian ophthalmologists and sheds light to the importance of assessing mental health among Canadian ophthalmologists at this time.
Similar studies have surveyed ophthalmologists in their respective countries during the COVID-19 pandemic and have found comparable rates of symptoms compared to this study.”
Comment 5: Is the age-distribution of the participants representative? I noted a relatively small variance.
Answer 5: The median (50th percentile) age category was 50-59 years old while the 25th percentile was 30-39 years and the 75th percentile was 60-69 years so we had a good distribution of respondent ages. According to the Canadian Medical Association, most ophthalmologists are in the age category 45-54 and 55-65 years (the reference data used different thresholds) which is similar to our results.
Comment 6: The abstract should summarize the main conclusions of the paper.
Answer 6: The conclusion of the abstract was further developed to better reflect the main conclusions of the paper as suggested.
Modifications 6:
ABSTRACT
“During the COVID-19 pandemic, up to 40% of respondents experienced varying degrees of depression, anxiety, insomnia, and distress from the event. In 12%, there were concerns for impaired daily functioning and/or suicidal thoughts.”
Reviewer 2 Report
Thank you for invitation to review this manuscript. I have few notes that improve the manuscript.
General comment: you have to specifically and explicitly indicate your sample (some times you used opthalmology practitioners, eye care clinicians, and opthalmologists. I recommend using opthalmologists across the whole study.
Abstract:
a) Line 21, no need for 60/85, or at least do not start a sentence with a number.
b) you may add any additions you will modify in your result section.
Introduction:
a) You need to explore more about the background of your study. You may get benefit from studies in table 1. Significance of the study as well as the problem statements is not well-defined in your introduction.
b) adding research questions (or specific aims) may improve the flow of the manuscript.
Materials and methods:
a) in line 69-70, on what bases you depend to include or exclude a questionnaire?
b) line 88, correct the cut-off points to become (equal or greater than 20)
c) indicate the number of items (22) and the responses for each item (0-4) for IES-R scale.
d) need more information about the validity and reliability of the instruments especially ISI and IES-R.
e) Statistical analysis was described clearly, however, did not show that in the result section.
Results:
a) Adequate description of the demographics.
b) It is not enough to report only the percentages of your variables, you need to present means (SD) for your study variables also.
Discussion: adequate and thorough
a) I do not see any need for table 2
b) any limitations and recommendations?
Author Response
Comments and Suggestions for Authors
Comment 1: Thank you for invitation to review this manuscript. I have few notes that improve the manuscript.
Answer 1: We would like to thank the reviewer for improving our article.
Comment 2: General comment: you have to specifically and explicitly indicate your sample (some times you used opthalmology practitioners, eye care clinicians, and opthalmologists. I recommend using opthalmologists across the whole study.
Answer 2: We thank the reviewer for this insight. To be uniform, we have changed all of the above terms to ophthalmologists and have previously defined that this includes ophthalmology trainees in the text (“All will be referred to as “ophthalmologists” unless level of training is specifically addressed.”).
Abstract:
Comment 3a) Line 21, no need for 60/85, or at least do not start a sentence with a number.
Answer 3a: The sentence was modified accordingly to not start the sentence with a number.
Modifications 3a:
ABSTRACT
“Of all responses, 60/85 answers were deemed complete and were included.”
Comment 3b) you may add any additions you will modify in your result section.
Answer 3b: Given that no other results were significant, we have not added additional results to the abstract (see answer to Comment 5e below).
Introduction:
Comment 4a) You need to explore more about the background of your study. You may get benefit from studies in table 1. Significance of the study as well as the problem statements is not well-defined in your introduction.
Answer 4a: As stated above, the introduction has been significantly reworked in response to the reviewers’ comments.
Modifications 4a:
INTRODUCTION
“This situation places ophthalmologists in a precarious position to continue offering care to patients at the risk of their own health and that of their loved ones. This has had an important impact on the mental health of ophthalmologists in various settings and countries, leading to significant depression, anxiety, stress, and insomnia in a third to two thirds of ophthalmologists abroad [3–8].
These changes can lead to further uncertainty and novelty which can affect the mental health of ophthalmologists.
We therefore sought to draw an overview of the state of mental health among ophthalmologists in Canada during the pandemic to provide national data to inform, destigmatize, and guide future interventions. We expected to find higher rates of anxiety, depression, stress, and insomnia among ophthalmologists in similar proportions to other countries, though this could be partially mitigated by robust infection control measures which decreased the relative number of cases nationally.”
Comment 4b) adding research questions (or specific aims) may improve the flow of the manuscript.
Answer 4b: We have addressed this at the end of the revised introduction.
Modifications 4b:
INTRODUCTION
“We therefore sought to draw an overview of the state of mental health among ophthalmologists in Canada during the pandemic to provide national data to inform, destigmatize, and guide future interventions. We expected to find higher rates of anxiety, depression, stress, and insomnia among ophthalmologists in similar proportions to other countries, though this could be partially mitigated by robust infection control measures which decreased the relative number of cases nationally.”
Materials and methods:
Comment 5a) in line 69-70, on what bases you depend to include or exclude a questionnaire?
Answer 5a: If there were missing answers to a questionnaire, this would not be deemed complete. Therefore, the excluded answers were only incomplete questionnaires or submissions that were started but not completed.
Modifications 5a:
MATERIALS AND METHODS – Study Design and Population
“Answers were considered for inclusion in this study if all questions were answered on at least one of the four questionnaires or if there was one written comment.”
RESULTS – Respondent Baseline Characteristics
“The 25 answers that were not included in the analysis consisted of respondents who started answering demographic questions but did not complete a questionnaire or write a freeform comment.”
Comment 5b) line 88, correct the cut-off points to become (equal or greater than 20)
Answer 5b: Thank you. This is a good catch by the reviewer. This was corrected in the revised manuscript.
Modifications 5b:
MATERIALS AND METHODS – Mental Health Questionnaires
“severe symptoms when equal or greater than 20”
Comment 5c) indicate the number of items (22) and the responses for each item (0-4) for IES-R scale.
Answer 5c: Thank you for the suggestion. This was added to the revised manuscript.
Modifications 5c:
MATERIALS AND METHODS – Mental Health Questionnaires
“Scores range from 0 to 88. There are 22 items scored from 0 to 4 describing different difficulties related to a stressful life event and respondents are asked to judge whether they were affected by these in the past seven days, either “Not at all”, “A little bit”, “Moderately”, “Quite a bit”, or “Extremely”. The total scores are categorized as follows…”
Comment 5d) need more information about the validity and reliability of the instruments especially ISI and IES-R.
Answer 5d: The ISI and IES-R are validated questionnaires for insomnia and post-traumatic stress disorder (see reference 20 & 22) and multiple studies (over 2000) have been published regarding those questionnaires. Further, those questionnaires were also used in similar studies regarding the mental health of health care workers during the pandemic as seen in Table 1. We commented on the choice of those questionnaires in the method section line 134.
Modifications 5d:
MATERIAL AND METHODS
“The authors decided to choose these questionnaires due to their previous validity in multiple studies, their common use in psychology, and their specific use in health care workers [3–8,19–27].”
Comment 5e) Statistical analysis was described clearly, however, did not show that in the result section.
Answer 5e: As stated in line 200-210, we have explained the results of our analysis with adequate presentation of the variables that are statistically significant. We have elaborated concisely on the other analyses that were not statistically significant in the revised manuscript.
RESULTS – Respondent Baseline Characteristics
“The median age category of respondents was 50-59 [30-39, 60-69] years”
RESULTS – Mental Health Questionnaire Results
“When comparing the mental health questionnaires’ scores among different demographic categories (i.e., age category, sex, language, training level, subspecialty), there were no discernable statistically significant differences. Regarding age categories, sex, language, training level, and subspecialties, there were no differences with regards to PHQ-9 categories (age p=0.49, sex p=0.59, language p=0.82, training p=0.32, and subspecialty p=0.80), GAD-7 categories (age p=0.80, sex p=0.44, language p=0.70, training p=0.55, subspecialty p=0.93), ISI categories (age p=0.67, sex p=0.93, language p=0.58, training p=0.44, subspecialty p=0.62), or IES-R categories (age p=0.49, sex p=0.97, language p=0.29, training p=0.57, subspecialty p=0.70), respectively.”
Results:
Comment 6a) Adequate description of the demographics.
Answer 6a: We thank the reviewer for the comment.
Comment 6b) It is not enough to report only the percentages of your variables, you need to present means (SD) for your study variables also.
Answer 6b: Since none of the continuous variables were normally distributed, these were all presented as median [first quartile, third quartile]. We removed information about presenting means and SD from the methods section.
Modifications 6b:
MATERIALS AND METHODS – Statistical Analysis
“Data are presented as median [first quartile, third quartile] for continuous, non-normally distributed variables and as frequencies (percentages) for categorical variables.”
Discussion: adequate and thorough
Comment 7a) I do not see any need for table 2
Answer 7a: To reduce redundancy in the manuscript, we have removed the Table 2 as suggested.
Modifications 7a:
DISCUSSION
“In the ophthalmology community, local to national associations have provided online resources to guide ophthalmologists, although none of the respondents in our study mentioned using resources.”
Comment 7b) any limitations and recommendations?
Answer 7b: We have elaborated on limitations in a section at the end of the discussion in the revised manuscript. We have also previously elaborated on possible recommendations based on our results in the discussion.
Modifications 7b:
DISCUSSION
“Among articles that have explored methods to mitigate symptoms of PTSD during the COVID-19 pandemic, some have found that clinicians with more disruption were less likely to access psychological material and resources [33]. Coping mechanisms proposed in previous studies include promoting individual positive lifestyle and mindfulness, using psychological resources, accessing digital psychological recommendations, and participating in therapeutic support groups. Institutional support of staff mental health and well-being is also essential. Methods include following public health measures, providing complete personal protective equipment, having regular information meetings and check-ups with the health care team, and providing psychological courses or hotline assistance. In the ophthalmology community, local to national associations have provided online resources to guide ophthalmologists, although none of the respondents in our study mentioned using these resources.
A limitation of this study includes the cross-sectional design which limits our information on the temporal relationship of COVID-19 and the onset of the mental health issues and limits the results to a specific time period in which the survey results may have been dependent on local COVID-19 rates. This was somewhat mitigated by sending reminders at the peaks of infectious waves to better reflect the impact of the pandemic on mental health. Additionally, despite two reminders to respond to the survey, there was a relatively low response rate among the membership of the Canadian Ophthalmological Society. This could be due in part to mental health stigma which may lead to selection bias wherein respondents who had significant symptoms may either be compelled to answer the survey or avoid answering it.”
Round 2
Reviewer 1 Report
The authors made sufficient revisions.
Reviewer 2 Report
Thank you for addressing all previous comments.
