Suicidal Ideation in People with Traumatic Spinal Cord Injury

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Given the clearly noted limitation of the current study, I think the overall good manuscript consists of a good written presentation of the study conducted by the authors.

Author Response

Reviewer 1

Given the clearly noted limitation of the current study, I think the overall good manuscript consists of a good written presentation of the study conducted by the authors.

Dear reviewer 1

Thank you very much for your valuable contributions and the time you dedicated to helping us improve our manuscript.

Your contribution was important to improve the quality of the article. Our gratitude.

We have improved the writing of the study, and we hope you will be satisfied. Best Regards

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity for reviewing this manuscript by Faleiros et al.

Overall, the study has presented some valuable data. The study is reasonably controlled, and the conclusions are supported by the data. However, the manuscript would benefit from better writing. This reviewer has identified some points/suggestions listed below for the authors to consider which may help to improve the manuscript:

1.     Re-write statements in lines 20-23 of the abstract.  

2.     There are occasional grammar, punctuation, or formatting errors throughout the manuscript, e.g. in lines 78, 244-246, etc…

3.     Be consistent in referring to ‘SurveyMonkey‘, use either with or without the trademark symbol, in line with the journal’s guidelines.

4.     Table 2, Consequence of injury: Percentage number (17.5) does not align with Paraplegia.

5.     What is a Bilateral Test (line 110)? Normally a chi-square test is used to find out the relationship between two categorical variables.

6.     Results section can be expanded. The authors have presented some valuable data in results section, however the body of the text does not sufficiently address/describe results. For instance, it is not clear what each number represents in table 3. Does the number under “Yes” and “No” refer to number of people who answered yes or no or something else.

7.     Table 2 and 3: No need to mention “Source: Prepared by the authors, 2023.”

8.     Tables lack proper caption/notes.

9.     The format of tables can also be improved to convey clearer information. It is not clear which part is table caption/note and which is body of the text for results section. For tables, the text and numbers might appear clearer if it is aligned to the left rather than the center.

10.  Consider changing the followings terms:

a.     “schooling” to level of education

b.     “time with injury” to injury duration

c.     “Future indications” (line 237) to future directions

d.     “automobile” to motor vehicle

e.     “sphincter control” (line 40) to fecal incontinence, if that is what you mean

11.  The authors have reported a significant association between the duration of injury and suicidal ideation. However, they have not mentioned how these two variables are associated. Did people with longer length of injury have higher suicidal ideation? The authors need to clarify this point in the results section and subsequently make relevant adjustments in discussion accordingly.

12.  There are repetitive statements in section 4.4 (Future Indications) in lines 238-243, indicating insufficient proof reading.

Comments on the Quality of English Language

As mentioned above, the manuscript would benefit from better writing. There are occasional grammar, punctuation, or formatting errors throughout the manuscript, some of which I have highlighted above.

Author Response

Reviewer 2

Thank you for the opportunity for reviewing this manuscript by Faleiros et al.

Overall, the study has presented some valuable data. The study is reasonably controlled, and the conclusions are supported by the data. However, the manuscript would benefit from better writing. This reviewer has identified some points/suggestions listed below for the authors to consider which may help to improve the manuscript:

1. Re-write statements in lines 20-23 of the abstract.

Reply: The text from lines 20 to 23 has been rewritten:

This is a quantitative, cross-sectional, descriptive study carried out in a virtual environment. A total of 200 people aged 18 or over with TSCI living in Brazil took part in the study. Data was collected using the Beck Scale for Suicidal Ideation, answered online by participants using SurveyMonkey®. The sample consisted of 200 participants, most of whom were male (74.5%), with a mean age of 36.22 years (SD=9.17), from southeast Brazil (65.5%), duration of injury of 134.4 months (approximately 11 years) (SD=128.40), and 32.5% frequency of suicidal ideation, as Suicidal ideation was also verified in relation to the variables of schooling, rehabilitation, and consequence of injury. A statistically significant relationship was found between the Duration of injury and suicidal ideation (p≤0.0085).

2. There are occasional grammar, punctuation, or formatting errors throughout the manuscript, e.g. in lines 78, 244-246, etc.

Reply: The text from line 78 has been rewritten:

At the Center for Research and Care in Neuropsychomotor Rehabilitation – Neurorehab of the Ribeirão Preto School of Nursing, University of São Paulo (EERP-USP).

The text from lines 244-246 has been rewritten:

Ferreira RS, Martin IS, Zanetti ACG, Vedana KGG. News about suicide in a Brazilian newspaper. Science. Ciênc Saude Colet. 2021; 26(4),1565-1574.

3. Be consistent in referring to ‘SurveyMonkey ‘, use either with or without the trademark symbol, in line with the journal’s guidelines.

 Reply: Corrected throughout. The term will be used: SurveyMonkey®

4. Table 2, Consequence of injury: Percentage number (17.5) does not align with Paraplegia.

Reply: Corrected. Number 17.5 is aligned with paraplegia, as is number 12 with tetraplegia.

5. What is a Bilateral Test (line 110)? Normally a chi-square test is used to find out the relationship between two categorical variables.

 Reply: It is used if the hypothesis is null. In a one-sided test there is only one critical value and in the case of a two-sided test there are two critical values symmetrical in relation to the expected value of the test variable.

6. Results section can be expanded. The authors have presented some valuable data in results section, however the body of the text does not sufficiently address/describe results. For instance, it is not clear what each number represents in table 3. Does the number under “Yes” and “No” refer to number of people who answered yes or no or something else.

Reply: The results section has been expanded.

7. Table 2 and 3: No need to mention “Source: Prepared by the authors, 2023.”

 Reply: Withdrawn.

8. Tables lack proper caption/notes.

 Reply: We've added more information in the notes/table legends.

9. The format of tables can also be improved to convey clearer information. It is not clear which part is table caption/note and which is body of the text for results section. For tables, the text and numbers might appear clearer if it is aligned to the left rather than the center.

 Reply: Information has been added to distinguish the notes from the tables.  All tables have been directed to the left as requested.

10. Consider changing the followings terms: a.“schooling” to level of education; b. “time with injury” to injury duration; c. “Future indications” (line 237) to future directions; d. “automobile” to motor vehicle; e. “sphincter control” (line 40) to fecal incontinence, if that is what you mean

Reply: The changes have been made.

11. The authors have reported a significant association between the duration of injury and suicidal ideation. However, they have not mentioned how these two variables are associated. Did people with longer length of injury have higher suicidal ideation? The authors need to clarify this point in the results section and subsequently make relevant adjustments in discussion accordingly.

 Reply: Rewritten in the text.

12. There are repetitive statements in section 4.4 (Future Indications) in lines 238-243, indicating insufficient proof reading.

Reply: This highlights the importance of early investigation and identification of suicidal ideation in people with TSCI and the development of studies that prioritize the identification of psychosocial needs, the improvement of care and the processes of rehabilitation, reintegration, and autonomy for these individuals.

Comments on the Quality of English Language:

As mentioned above, the manuscript would benefit from better writing. There are occasional grammar, punctuation, or formatting errors throughout the manuscript, some of which I have highlighted above.

Reply: We apologize sincerely. We inform you that the repairs have been carried out and we thank you for your kindness in helping us.

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript describes the tendency of suicide attempt in people with traumatic spinal cord injury by a descriptive manner. Data was collected via SurveyMonkey web system.

Line 129

Presentation in Table 2 should be percentage of (positives in a subgroup / all in a subgroup). Current presentation seems (subgroup positives / all positives).

Line 193

If the presentation in Table 2 is inappropriate, discussion should be re-constructed.

Line 201

As for time after injury, nature of relationships, positive or negative, should be clearly discussed. Current study presents relationship between longer suffer (?) and no suicidal ideation. This may be mental recovery and should be carefully discussed.

Author Response

Reviewer 3

This manuscript describes the tendency of suicide attempt in people with traumatic spinal cord injury by a descriptive manner. Data was collected via SurveyMonkey web system.

Line 129

Presentation in Table 2 should be percentage of (positives in a subgroup / all in a subgroup). Current presentation seems (subgroup positives / all positives).

Reply: After all the reading and guidance, we decided to remove table 2.

Line 193

If the presentation in Table 2 is inappropriate, discussion should be re-constructed.

 Reply: After all the reading and guidance, we decided to remove table 2.

Line 201

As for time after injury, nature of relationships, positive or negative, should be clearly discussed. Current study presents relationship between longer suffer (?) and no suicidal ideation. This may be mental recovery and should be carefully discussed.

Reply: Rewritten in the text.

Reviewer 4 Report

Comments and Suggestions for Authors

Interesting study. Respected methodology, correct references. It is necessary to expand the introduction and materials and methods (especially in the inclusion and exclusion part)

Author Response

Reviewer 4

Interesting study. Respected methodology, correct references. It is necessary to expand the introduction and materials and methods (especially in the inclusion and exclusion part).

Reply: The introduction and methods have been reformulated and expanded.

Reviewer 5 Report

Comments and Suggestions for Authors

Dear Authors,

First, I would like to commend the authors for undertaking such a significant and interesting research study. The topic addressed is of immense importance and has the potential to provide valuable insights to the academic community. However, there are several areas within the manuscript that would benefit from further elaboration and clarification to ensure its maximum impact. Please consider the following suggestions:

1. Lines 20-21: The sentences seem incomplete. For clarity, please review and revise to provide an understandable message.

2. Lines 25-27: While p-value data is presented, it would improve the usefulness of the message to provide the actual value of the correlation coefficients.

3. Line 23: A reference to participants is noted. Please specify the theoretical population or provide a description of the profile and nature of these participants.

4. Lines 64-66: The description of the study design seems incomplete. It would be beneficial to clarify that a self-completion questionnaire was used. Please also explain the circumstances of data collection: location, presence of an assistant, etc. Moreover, the term "virtual environment" (line 65) may be misinterpreted as referring to a virtual reality setting.

5. Line 74: Were the 700 volunteers preselected? If so, according to what criteria? Or are they all clients of the center mentioned?

6. Line 88: The term "21 groups of statements" is used. Could you provide the total number of statements? In addition, the description of the scale needs to be elaborated in terms of its purpose, dimensionality, intended population, limitations, and reference values. Also, mention whether the scale's recommended method of administration was followed or modified.

7. Lines 96-98: The information provided seems unclear. Can you provide more clarity?

8. Line 107: There seems to be a discrepancy as some data is presented in percentages. Please review and correct.

9. Table 1: Expand on the participation of students in different grades, especially considering the age range of participants. How it comes that you have participants from elementary school when the population is aged 18+?

10. Table 2: Add information on the results of the significance test for differences between subgroups (the text says that these differences are not statistically significant, but the related empirical evidence is missing).

11. Explain the meaning of the variable "Rehabilitation" - meaning present, past, circumstances of its implementation, relevance of the variable to the analysis being conducted.

12. What is the value of "positive percentage" for the whole dataset? While this value seems to be mentioned in the "discussion", it should definitely be listed directly in this table.

13. Instead of presenting the differences in percentages, give the results of the regression analysis (presumably a binary logistic regression, given the nature of the variables). In this form, the results obtained are difficult to apply in practice and their interpretability is very limited.

13. Table 3: Please define terms such as "complete" and "incomplete" in the context of TSCI.

14. Also, consider using row percentages rather than absolute values for "sex". You will find that the comment in the discussion (lines 163-169) is wrong, as the results are exactly the opposite.

15. Please, consolidate the format of Tables 2 and 3.

16. Table 4: There seems to be confusion between dependent and independent variables. Please revisit and correct.

17. Lines 140-143: Rewrite to emphasize differences between subgroups rather than associations and relationships.

18. Lines 153-154: please add specific empirical evidence for the claim.

19. Lines 155-156: please provide specific empirical evidence for the claim.

20. Line 157: please compare the reported value with specific values found in other studies. Attempt a comparison with the general population, or provide an adequate benchmark.

21. Lines 160-162: Consider the impact in a form of the disruption of daily activities.

22. Row 164: it is not clear from comparison with the data in the table whether this is for the absolute number of responses (i.e., 43 males) or a percentage (i.e., 43% of males).

23. Lines 179 & 185-186: Please explain the relationship and relevance of the qualitative study to your current findings and results.

24. Lines 185-186: However, this information does not explain the results you obtained in your study. Please clarify.

25. Lines 193-200: The conclusions presented would gain validity with age-controlled analysis

26. Lines 205-208: The conclusions presented would gain validity with reevaluation of the dependent and independent variables in your analysis.

27. Lines 231-236 (4.2 Limitations): It is important to acknowledge all potential limitations. A major limitation seems to be the reliance on verbal reports without verification. Please enrich this section with a comprehensive discussion of all potential pitfalls.

In conclusion, while the study offers a fresh perspective on the topic, addressing the concerns raised will greatly enhance its quality and impact. Major revisions are absolutely necessary prior to resubmission. Thank you for your contribution, and I look forward to seeing the refined version of your manuscript.

Sincerely,

Comments on the Quality of English Language

Incomplete sentences.

Author Response

Reviewer 5

Dear Authors,

First, I would like to commend the authors for undertaking such a significant and interesting research study. The topic addressed is of immense importance and has the potential to provide valuable insights to the academic community. However, there are several areas within the manuscript that would benefit from further elaboration and clarification to ensure its maximum impact. Please consider the following suggestions:

1. Lines 20-21: The sentences seem incomplete. For clarity, please review and revise to provide an understandable message.

Reply: The sentences have been rewritten.

2. Lines 25-27: While p-value data is presented, it would improve the usefulness of the message to provide the actual value of the correlation coefficients.

Reply: The sentences have been rewritten.

3. Line 23: A reference to participants is noted. Please specify the theoretical population or provide a description of the profile and nature of these participants.

Reply: The sentences have been rewritten.

4. Lines 64-66: The description of the study design seems incomplete. It would be beneficial to clarify that a self-completion questionnaire was used. Please also explain the circumstances of data collection: location, presence of an assistant, etc. Moreover, the term "virtual environment" (line 65) may be misinterpreted as referring to a virtual reality setting.

Reply: The sentences have been rewritten.

5. Line 74: Were the 700 volunteers preselected? If so, according to what criteria? Or are they all clients of the center mentioned?

Reply: At the time of data collection, there were 700 individuals registered in the database. Links to the questionnaire were sent to all these volunteers, 200 of whom responded.

6. Line 88: The term "21 groups of statements" is used. Could you provide the total number of statements? In addition, the description of the scale needs to be elaborated in terms of its purpose, dimensionality, intended population, limitations, and reference values. Also, mention whether the scale's recommended method of administration was followed or modified.

Reply: The sentences have been rewritten.

7. Lines 96-98: The information provided seems unclear. Can you provide more clarity?

Reply: It has been added to the text: A form based on the Core Dataset® developed by the International Spinal Cord Society (ISCOS) [9] was used to characterize the study participants. This questionnaire assessed sociodemographic such as date of birth, rehabilitation service attended, level of spinal cord injury, city and state, level of education, occupation, and family income. Information regarding the severity of the spinal cord injury, details of hospitalization and the use of ventilatory support (e.g., mechanical ventilation) was not investigated because the ISCOS was self-administered, and participants were unable to answer more in-depth questions about their clinical condition.

8. Line 107: There seems to be a discrepancy as some data is presented in percentages. Please review and correct.

Reply: Rewritten in the text.

9. Table 1: Expand on the participation of students in different grades, especially considering the age range of participants. How it comes that you have participants from elementary school when the population is aged 18+?

Reply: The question about education refers to the number of years the participants have studied. Considering social inequality, economic polarity, the few and scarce opportunities for many Brazilians to study, especially those with disabilities, these figures are true. We hope that this information will change the world view of many people/readers of this study so that everyone realizes that it is possible to be over 18 and not have completed primary school. We are not a first world country, and we are a long way from this reality. We hope we've answered your questions.

10. Table 2: Add information on the results of the significance test for differences between subgroups (the text says that these differences are not statistically significant, but the related empirical evidence is missing).

Reply: Reorganized.

11. Explain the meaning of the variable "Rehabilitation" - meaning present, past, circumstances of its implementation, relevance of the variable to the analysis being conducted.

Reply: Inserted in the text.

12. What is the value of "positive percentage" for the whole dataset? While this value seems to be mentioned in the "discussion", it should definitely be listed directly in this table.

Reply: After all the reading and guidance, we decided to remove table 2.

13.a Instead of presenting the differences in percentages, give the results of the regression analysis (presumably a binary logistic regression, given the nature of the variables). In this form, the results obtained are difficult to apply in practice and their interpretability is very limited.

Reply: Thank you kindly for your suggestion in this thread.

13.b Table 3: Please define terms such as "complete" and "incomplete" in the context of TSCI.

Reply: Complete spinal cord injury: there is no function below the level of the injury - no sensation and no voluntary movement. Incomplete spinal cord injury: there is some function below the primary level of the injury.

14. Also, consider using row percentages rather than absolute values for "sex". You will find that the comment in the discussion (lines 163-169) is wrong, as the results are exactly the opposite.

Reply: Reorganized.

15. Please, consolidate the format of Tables 2 and 3.

Reply: After all the reading and guidance, we decided to remove table 2.

16. Table 4: There seems to be confusion between dependent and independent variables. Please revisit and correct.

Reply: Reorganized.

17. Lines 140-143: Rewrite to emphasize differences between subgroups rather than associations and relationships.

Reply: Reorganized.

18. Lines 153-154: please add specific empirical evidence for the claim.

Reply: Reorganized. We emphasize that the empirical evidence has been covered in the discussion.

19. Lines 155-156: please provide specific empirical evidence for the claim.

Reply: Reorganized. We emphasize that the empirical evidence has been covered in the discussion.

20. Line 157: please compare the reported value with specific values found in other studies. Attempt a comparison with the general population, or provide an adequate benchmark.

Reply: Reorganized.

21. Lines 160-162: Consider the impact in a form of the disruption of daily activities.

Reply: Reorganized.

22. Row 164: it is not clear from comparison with the data in the table whether this is for the absolute number of responses (i.e., 43 males) or a percentage (i.e., 43% of males).

Reply: Reorganized.

23. Lines 179 & 185-186: Please explain the relationship and relevance of the qualitative study to your current findings and results.

Reply: Answered in the text of the article.

24. Lines 185-186: However, this information does not explain the results you obtained in your study. Please clarify.

Reply: Answered in the text of the article.

25. Lines 193-200: The conclusions presented would gain validity with age-controlled analysis

Reply: Answered in the text of the article.

26. Lines 205-208: The conclusions presented would gain validity with reevaluation of the dependent and independent variables in your analysis.

Reply: Answered in the text of the article.

27. Lines 231-236 (4.2 Limitations): It is important to acknowledge all potential limitations. A major limitation seems to be the reliance on verbal reports without verification. Please enrich this section with a comprehensive discussion of all potential pitfalls.

Reply: Limitations include the use of a cross-sectional model, which makes it impossible to identify cause and effect relationships between the variables explored. It is also pointed out that collecting data through a virtual platform may have limited and hindered the participation of a portion of the Brazilian population without Internet access. In this sense, studies that include the collection of data from people without Internet access could add other relevant data. Another limitation concerns the adaptation of the data collection tool, given the need to reorganize the logic of the groups of statements that made up the scale when the tool was transferred to the digital platform.

In conclusion, while the study offers a fresh perspective on the topic, addressing the concerns raised will greatly enhance its quality and impact. Major revisions are absolutely necessary prior to resubmission. Thank you for your contribution, and I look forward to seeing the refined version of your manuscript.

Sincerely,

We tried to make as many changes as possible so that all the reviewers' guidelines were met. All the suggestions were excellent for improving the study and we ask you to understand if any of your recommendations were not heeded.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

This is a good revision, handling various concerns raised to initial version.

Minor point:

Line 305:  (15-18, 20-21] should be  [15-18, 20-21] .

Author Response

Dear reviewer 3

Thank you very much for your words and contributions.

Below is the response to the last request.

Minor point: Line 305: (15-18, 20-21] should be [15-18, 20-21].

The change has been made and is highlighted in the text.

Best regards

Reviewer 5 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for improved manuscript; I do not have any other comments.

Congratulations,

Author Response

Dear reviewer 5

Thank you very much for your words and contributions.

Best regards