Thought Beyond the Inkblots: One-Year Follow-Up in a Cohort of Italian Adolescents with Psychotic Symptoms

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Below are some comments on your article aimed at improving the quality of the research:

• The study’s approval by the Ethics Committee and compliance with the Declaration of Helsinki highlight a strong commitment to ethical research practices. However, in reference to the Declaration of Helsinki and its amendments, the authors could provide a note explaining how specific amendments influenced the study design.

• While the age range is specified, relevant demographic data should also be provided, as these factors could influence the results and are crucial for understanding the generalisability of the study.

• It would be beneficial to clarify more thoroughly within the exclusion criteria the reasons for excluding patients with BLIPS.

• The date range mentioned, from October 2019 to July 2022, includes the period of the COVID-19 pandemic, which may have impacted data collection. The authors should address this situation.

• The authors should provide a more detailed clarification regarding the participants who completed the one-year follow-up and include information about potential dropout rates.

Author Response

Comment: The study’s approval by the Ethics Committee and compliance with the Declaration of Helsinki highlight a strong commitment to ethical research practices. However, in reference to the Declaration of Helsinki and its amendments, the authors could provide a note explaining how specific amendments influenced the study design.

Reply: Thank you for your valuable comment. We have added a note in the Desing section to explain how specific amendments to the Declaration of Helsinki influenced our study design. In particular, we focused on the application of the guidelines for obtaining informed consent from underage participants and ensuring the protection of vulnerable populations.

World Medical Association. (2000). Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA, 284(23), 3043–3045. https://doi.org/10.1001/jama.284.23.3043

World Medical Association. (2013). Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA, 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053

 

Comment: While the age range is specified, relevant demographic data should also be provided, as these factors could influence the results and are crucial for understanding the generalizability of the study.

Reply: We did not collect additional sociodemographic information for this study. The patients did not consent to sharing any data beyond these. However, if the reviewer is interested in any specific demographic aspect, we can try to provide it.

 

Comment: It would be beneficial to clarify more thoroughly within the exclusion criteria the reasons for excluding patients with BLIPS.

Reply: We thank the reviewer for this comment. Literature in this field suggested to homogenize the CHR-P group, excluding adolescents who met BLIPS group criteria, given the phenotypic overlap of this subgroup with the EOP one. We also followed this suggestion in previous studies (i.e., Mensi et. al, 2023, doi: 10.1186/s13034-023-00567-1.)

 

Comment: The date range mentioned, from October 2019 to July 2022, includes the period of the COVID-19 pandemic, which may have impacted data collection. The authors should address this situation.

Reply: Thank you for pointing out the potential impact of the COVID-19 pandemic on our data collection. We acknowledge that the pandemic has significantly influenced mental health service utilization, leading to an increase in access to care. Consequently, our sample size during the period from October 2019 to July 2022 is likely larger than it would have been in a similar timeframe outside of the pandemic.

 

Comment: The authors should provide a more detailed clarification regarding the participants who completed the one-year follow-up and include information about potential dropout rates.

Reply: We added sociodemographic information about the follow-up sample.

Reviewer 2 Report

Comments and Suggestions for Authors

This study explores how the Rorschach Performance Assessment System (R-PAS) can predict Clinical High Risk for Psychosis (CHR-P) in adolescents. It addresses a meaningful topic with strong clinical and theoretical significance. The longitudinal design adds credibility to the findings, and the integration of Rorschach data with follow-up diagnoses makes the study both robust and insightful. Overall, this research makes a valuable contribution to understanding psychosis risk and presents a methodologically sound approach. However, addressing some of the following issues—particularly regarding sample size, statistical interpretation, and the depth of discussion—will further strengthen the manuscript. With these revisions, the paper is well-suited for publication.

Introduction

1. Background: The introduction does a good job of covering CHR-P and Rorschach testing. That said, the discussion on the historical development of Rorschach testing feels a bit long. Shortening this part could help keep the focus on the main objectives of the study.
2. Research Gap: While the novelty of using R-PAS is highlighted, the specific shortcomings of earlier studies with other Rorschach methods are not clear. Adding a brief explanation of why previous approaches are inadequate would make the rationale stronger.

Methods

1. Sample Size: The small sample size in the Early Onset Psychosis (EOP) group (n=23, and even fewer in some subgroup analyses) is a limitation. It would be helpful to address this issue more directly, explaining how it might impact the reliability of the findings.
2. Control Group: Using a non-APS group of psychiatric patients rather than healthy controls makes the results harder to interpret. This limitation should be clearly discussed in the paper.
3. Statistical Analysis: The manuscript mentions using Bonferroni correction, but it would be useful to briefly explain why this method was chosen and how it affects the interpretation of the results.

Results

1. Clarity of Findings: The results are detailed, but the section could be easier to follow with a clearer structure. For instance, separating baseline and follow-up analyses under distinct subheadings would help readers navigate the findings.
2. Interpretation of Metrics: Some key findings, like the predictive power of the Ego Impairment Index-3 (EII-3), are not fully interpreted. Connecting these findings to their clinical significance would make the results more meaningful.

Discussion

1. Comparison with Prior Research: The discussion highlights the study’s novel findings, but it would be even stronger if it compared these results with previous studies on CHR-P or predictive tools like CAARMS.
2. Medication Effects: The paper discusses medication effects in the EOP group but does not address this for APS patients. Including this analysis would make the discussion more comprehensive.
3. Clinical Implications: The section on clinical applications could go deeper, especially on how specific R-PAS metrics like EII-3 or V-Comp might inform intervention strategies.
4. Limitations: While some limitations are mentioned, more emphasis should be placed on the lack of a healthy control group and the potential bias introduced by recruiting from a clinical setting.

Other issues

1. Language: The language is generally clear, but a careful review of grammar and phrasing before publication is recommended to ensure readability.
2. Terminology: Terms like "Rorschach test" and "R-PAS" are sometimes used interchangeably, which might confuse readers. Consistent terminology would improve clarity.
3. Formatting: Consider adding more visualizations, such as box plots or heatmaps, to present the results more intuitively；The sampling flowchart could benefit from clearer presentation, with higher-resolution images for better readability；Figures, especially critical ones, should be of sufficient resolution to meet publication standards.

 

 

 

 

 

 

Comments for author File: Comments.pdf

Author Response

Comment: This study explores how the Rorschach Performance Assessment System (R-PAS) can predict Clinical High Risk for Psychosis (CHR-P) in adolescents. It addresses a meaningful topic with strong clinical and theoretical significance. The longitudinal design adds credibility to the findings, and the integration of Rorschach data with follow-up diagnoses makes the study both robust and insightful. Overall, this research makes a valuable contribution to understanding psychosis risk and presents a methodologically sound approach. However, addressing some of the following issues—particularly regarding sample size, statistical interpretation, and the depth of discussion—will further strengthen the manuscript. With these revisions, the paper is well-suited for publication.

Reply: We answered the reviewer’s comments point-by-point.

 

Comment: Introduction

Background: The introduction does a good job of covering CHR-P and Rorschach testing. That said, the discussion on the historical development of Rorschach testing feels a bit long. Shortening this part could help keep the focus on the main objectives of the study.

Research Gap: While the novelty of using R-PAS is highlighted, the specific shortcomings of earlier studies with other Rorschach methods are not clear. Adding a brief explanation of why previous approaches are inadequate would make the rationale stronger.

Reply: Dear Reviewer, thank you for your comment. We attempted to shorten the historical development of R-PAS but found it necessary to retain references to the CS due to the methodological continuity of their indices. Moreover, we emphasized the importance of the most recent normative data sample to justify our choice. Other methodological advantages of the R-PAS could have been discussed, but as you noted, this would have shifted the focus of the introduction too heavily toward Rorschach historical and methodological issues and controversies.

 

Comment: Methods

Sample Size: The small sample size in the Early Onset Psychosis (EOP) group (n=23, and even fewer in some subgroup analyses) is a limitation. It would be helpful to address this issue more directly, explaining how it might impact the reliability of the findings.

Reply: Thank you for pointing out this important limitation. We acknowledge that the small sample size in the Early Onset Psychosis (EOP) group, particularly in some subgroup analyses, is a constraint. This limited sample size may affect the reliability and generalizability of the findings, as smaller groups are more susceptible to variability and may not fully represent the broader population. To address this, we have added a discussion in the manuscript highlighting this limitation and encouraging caution in interpreting the results. Additionally, we propose that future studies with larger and more diverse samples are needed to validate and expand upon these findings.

Comment: Control Group: Using a non-APS group of psychiatric patients rather than healthy controls makes the results harder to interpret. This limitation should be clearly discussed in the paper.

Reply: Thank you for highlighting the absence of a neutral control group as a limitation of our study. We hope to have now addressed this point in the discussion section of the manuscript and suggest that future research should aim to incorporate a neutral control group to enhance the robustness of comparisons.

 

Comment: Statistical Analysis: The manuscript mentions using Bonferroni correction, but it would be useful to briefly explain why this method was chosen and how it affects the interpretation of the results.

Reply: Thank you for your valuable comment. We discuss this choice in the manuscript and acknowledge that future studies with larger sample sizes may allow for less conservative correction methods.

 

Comment: Results

Clarity of Findings: The results are detailed, but the section could be easier to follow with a clearer structure. For instance, separating baseline and follow-up analyses under distinct subheadings would help readers navigate the findings.

Reply: We have separated the discussion and results into Study 1 and Study 2, hoping that this will facilitate readability.

 

Comment: Interpretation of Metrics: Some key findings, like the predictive power of the Ego Impairment Index-3 (EII-3), are not fully interpreted. Connecting these findings to their clinical significance would make the results more meaningful.

Reply: Thank you for your insightful comment. We agree that the predictive power of the Ego Impairment Index-3 (EII-3) is an important finding, and we have now expanded the interpretation of this metric in the manuscript. We believe that this addition enhances the meaningfulness of the results and helps contextualize their relevance for clinical practice.

 

Comment: Discussion

Comparison with Prior Research: The discussion highlights the study’s novel findings, but it would be even stronger if it compared these results with previous studies on CHR-P or predictive tools like CAARMS.

Reply: We updated the manuscript accordingly. We cited a recent study on the predictive properties of CAARMS (Hartmann, S.; Dwyer, D.; Cavve, B.; Byrne, E.M.; Scott, I.; Gao, C.; Wannan, C.; Yuen, H.P.; Hartmann, J.; Lin, A.; et al. Development and Temporal Validation of a Clinical Prediction Model of Transition to Psychosis in Individuals at Ultra-High Risk in the UHR 1000+ Cohort. World Psychiatry 2024, 23, 400–410, doi:10.1002/wps.21240)

 

Comment: Medication Effects: The paper discusses medication effects in the EOP group but does not address this for APS patients. Including this analysis would make the discussion more comprehensive.

Reply: We appreciated this valuable comment. Studying the effects of antipsychotics was not the aim of the study, so we made these comparisons to be able to explain one of the results from the comparison between groups. Unfortunately, the research design did not include medication control, and the resulting limitations do not allow us to propose more precise analyses and valid interpretations with respect to the effects of antipsychotics on performance at R-PAS. If the reviewers feel that this result is too far-fetched, we simply propose to remove it from the analysis and discussion.

 

Comment: Clinical Implications: The section on clinical applications could go deeper, especially on how specific R-PAS metrics like EII-3 or V-Comp might inform intervention strategies.

Reply: Based on recommendations in the literature for the treatment of psychosis, we have included treatment considerations focused on person-centered interventions (psychotherapy, mindfulness, relaxation techniques) that take into account the vulnerabilities identified in the at-risk group

 

Comment: Limitations: While some limitations are mentioned, more emphasis should be placed on the lack of a healthy control group and the potential bias introduced by recruiting from a clinical setting.

Reply: We have highlighted the limitation of this aspect. However, the scores provided by the analyses are in standard scores (SS), allowing the reader to gain an idea of the comparison with the normative sample. While this does not solve the issue of a comparison with a control sample, it can still provide insight into the scores we might expect relative to the reference sample.

 

Comment: Other issues

Language: The language is generally clear, but a careful review of grammar and phrasing before publication is recommended to ensure readability.

Reply: We extensively revised grammar and phrasing to make the manuscript more readable.

 

Comment: Terminology: Terms like "Rorschach test" and "R-PAS" are sometimes used interchangeably, which might confuse readers. Consistent terminology would improve clarity.

Reply: Dear reviewer, thank you for this suggestion. Indeed, it is rather confusing. We have replaced the term 'Rorschach' with 'R-PAS' throughout the article, except where the full name of 'R-PAS' is used (since the 'R' stands for Rorschach) and in the keywords, where we believe it may be more advantageous for those searching for information on the Rorschach to find it by using 'Rorschach' rather than 'R-PAS'.

 

Comment: Formatting: Consider adding more visualizations, such as box plots or heatmaps, to present the results more intuitively；The sampling flowchart could benefit from clearer presentation, with higher-resolution images for better readability；Figures, especially critical ones, should be of sufficient resolution to meet publication standards.

Reply: We have reduced the length of the tables by adding box plots and graphs of the main sociodemographic variables. Moreover, we added figures with higher resolution.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

the comments in the annex file.

Best

Comments for author File: Comments.pdf

Author Response

Title: Thought beyond the inkblots: one-year follow-up in a cohort of adolescents with psychotic symptoms

Dear Authors,

Comment: First of all, I would like to express my sincere thanks for giving me the opportunity to contribute my opinion to the evaluation of your manuscript. I found the topic discussed extremely interesting and relevant to the field in which we operate. The research presents several useful and promising insights that could bring significant advancements to our field. However, after a thorough reading, I believe there are some aspects that need to be improved and clarified to allow for a full appreciation of the proposed work. Below, I list the main areas that could benefit from further exploration and revision.

Reply: We appreciated the reviewer's time to read our work and give precious suggestions.

 

Comment: Title

Good, although the study setting could help the reader more easily (e.g., “In Italy”).

Reply: We appreciated the suggestion. We addressed it by adding “Italian”. The new title is “Thought beyond the inkblots: one-year follow-up in a cohort of Italian adolescents with psychotic symptoms”.

 

Comment: Abstract

Good. Perhaps a greater focus on the possible implications for clinical practice in the conclusions, and results more focused on the quantitative aspect rather than the narrative one.

Reply: We appreciated the reviewer’s suggestion. We deeply revised the abstract to make it clear and readable.

 

Comment: Keywords：I would reduce them to 4 or 5, possibly choosing those most relevant to the study, in line with the title.

Reply: We followed the suggestion and removed “functioning” and “prevention”.

 

Comment: Objectives

Not very clear and incisive (lines 51-57); I suggest the classic formula “our study aims to…” and to structure them into primary and secondary objectives.

Reply: We added the two main aims to make the manuscript more transparent.

 

Comment: Introduction

In my opinion, an epidemiological context (both international and regional) is missing, which I would include at the beginning of the manuscript, again focusing more on the quantitative aspect rather than the descriptive one.

Reply: We thank the reviewer for the valuable feedback. We appreciated the suggestion to include an epidemiological context, as it would provide a solid foundation for the manuscript and enhance the readers' understanding of the study's relevance.

 

Comment: Methods

They have strengths and rigor, especially in terms of reporting, but at the same time, there are aspects that I would delve into more deeply, following the STROBE guidelines.

Reply: We have taken steps to make the manuscript more rigorous, including implementing aspects contained in the STROBE guidelines. We have attached the strobes as Supplementary. In order to improve, we would like to know what aspect is missing from the STROBE guidelines, according to the reviewer.

 

Comment: Results

I would reconsider "lightening" the text by reducing the tables produced, perhaps extracting the key elements and placing them in the appendices in full. They are also missing legends, which make it difficult for the reader to understand. Furthermore, the summary of the results in 4 pages is condensed into only 7 lines in total.

Reply: We appreciated this suggestion. We have reduced the length of the tables by adding box plots and graphs of the main sociodemographic variables. We also added legends for the R-PAS variables below Table 2, Table 3, and Table 4.

 

Comment: Discussion

In my opinion, this section should be completely revised or at least significantly reworked. The first aspect to reconsider is the breadth, which, however, does not translate into

concrete discussion points, perhaps on elements that could interact with or enhance the studied phenomenon, such as the reckless use of the internet by the studied population, substance use, or their awareness. I would like to suggest some references that could help expand and improve this part of the manuscript:

https://pubmed.ncbi.nlm.nih.gov/37601984/

https://doi.org/10.3390/psychiatryint6010001

https://pubmed.ncbi.nlm.nih.gov/19771144/

Additionally, I would include environmental factors in general that may influence the overall clinical picture.

Reply: We have reorganized the discussion to make it more precise and more informative for the reader. Thank you for this suggestion. Moreover, we do not have additional sociodemographic information beyond what has been shared, and we do not actually know how these adolescents used the internet. However, we have added comments regarding the homogeneity of our sample and how this may limit the generalizability of our results to the tested population (Caucasian, middle socioeconomic status, age).

 

Comment: References

Good. They just need to be expanded in the suggested areas and perhaps updated (if possible) for older references (over 10/15 years). For those older than this period, unless there is clear evidence of extreme effectiveness or necessity from a methodological standpoint, I would advise against using them to support the manuscript content.

Reply: Research using the Rorschach on this topic dates back to the CS system, which has not been updated. Therefore, we are unaware of more recent studies on the subject (ie, APS vs EOP), even with the CS.

 

Comment: In summary, the manuscript presents scientifically significant results but requires a series of methodological and structural improvements to enhance its overall quality. My advice is to proceed with a thorough revision addressing these points before moving forward with publication, as, if appropriately modified, the manuscript could represent a valuable contribution to the relevant scientific literature.

Reply: We appreciated the reviewer’s valuable comments and look forward to reading his/her impressions about the revision.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors,
We sincerely appreciate your comments and the modifications made to the article, which significantly enhance its scientific quality and academic rigor.

Author Response

Comment: Dear authors,

We sincerely appreciate your comments and the modifications made to the article, which significantly enhance its scientific quality and academic rigor.

Response:  We thank the reviewer for the valuable feedback. We are glad that the reviewer appreciated the new version.

Reviewer 2 Report

Comments and Suggestions for Authors

The authors took the reviewers' suggestions very seriously and made targeted changes, and the quality of the revised manuscript was substantially improved. If there are no formatting issues, it is recommended to accept

Author Response

Comment: The authors took the reviewers' suggestions very seriously and made targeted changes, and the quality of the revised manuscript was substantially improved. If there are no formatting issues, it is recommended to accept

Response: We really appreciated the valuable reviewer’s comments. We are glad that the updated version aligns with the reviewer’s expectations.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

the comments in the annex file. I suggest again native review of the manuscript.

Best

Comments for author File: Comments.pdf

Comments on the Quality of English Language

I suggest native review update.

Author Response

Comment: Dear Authors,

the comments in the annex file. I suggest again native review of the manuscript.

Best

Response: We thank the reviewer. We addressed all the comments to make the manuscript more precise and had extensive English editing to make it more fluent.

 

Comment: Dear Authors,

Two fundamental aspects remain unresolved:

the reference for the STROBE method for reporting (the supplementary file is fine), and I would like to clarify to the authors that this is not a request for missing or incomplete elements, but rather for the scientific validity of the manuscript and its support for scientific dissemination in an indexed journal. I remind the authors that for some publishers, this is a mandatory element prior to submission.

Response: We thank the reviewer for the clarification and valuable input. As suggested, we have included the missing reference and specified the title in the Supplementary Files section.

 

Comment: I would also like to add that the flow chart of the study needs to be made clearer and more understandable, as upon careful review, it appears to be difficult for the reader to understand.

Response: We thank the reviewer for this suggestion. We modified the flow chart to make it more understandable for the reader.

Round 3

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

in this form only editing improvements missing:

• the study flow chart missing in legend;
• the Figure purpose merit major improvements for resolution (principally 3, 5, 6);
• Attention because missing conclusion part.

Author Response

Comment: Dear Authors,

in this form only editing improvements missing:

the study flow chart missing in legend;

the Figure purpose merit major improvements for resolution (principally 3, 5, 6);

Attention because missing conclusion part.

Response: We appreciated the reviewer’s suggestions. We added the proper legend for Figure 1 and for the others where legends were missing. Moreover, we improved the Figures' quality and resolution. Finally, we added the conclusion part, as required.