Mental Health Outcomes Among Physicians Following the COVID-19 Pandemic

Round 1

Reviewer 1 Report

1. In the Material and Methods section, it is mentioned that 200 doctors were invited to the study. Is it known what is the exact number of physicians across the country who worked in the frontline during that period? What is the percentage of physicians included in the research?
2.  In the Material and Methods section, page 2: what does “... as well as in the private sector, all of them through our personal acquaintances” mean?
3. In section 3.2 Participants’ experiences, it is indicated “mean 28.56 ± 29.32 hours per week”, although from a statistical point of view it may be correct, this average may signal a very asymmetric distribution. In such cases, it is more appropriate to report the median and/or the interquartile range.

In Table 1, the Age variable, under Categories - what does the value 3 mean? Check for errors.

Author Response

We sincerely thank the reviewer for the careful evaluation of our manuscript.

Author Response File: Author Response.docx

Reviewer 2 Report

The manuscript addresses a relevant and socially significant topic. However, it shows methodological limitations, writing inconsistencies, and insufficient discussion depth. The small sample size and lack of multivariate analysis limit generalizability. Novelty: moderate.

The study investigates the prevalence of anxiety, depression, and PTSD among Greek physicians who worked on the COVID-19 and explores associations between exposure variables and mental outcomes.

Title “Association of the COVID-19 Pandemic with…” is somewhat misleading — the study was conducted after the pandemic and measures self-reported symptoms, not causal associations. Suggestion: mental health outcomes among physicians following/after COVID-19 pandemic.”

Introduction identifies ethical and emotional burdens during COVID-19 and situates Greek physicians within this global context. The conceptual moral distress vs PTSD is interesting but not directly tied to the measured outcomes.

The research gap is implied rather than clearly stated. End with a gap statement: “To date, no studies have systematically examined the persistence of anxiety, depression, and PTSD symptoms among Greek physicians using validated instruments post-pandemic….”

Ethical approval and consent process are transparent.

Instruments (PHQ-4, IES-R-Gr) are validated and cited properly.

Convenience sampling from personal acquaintances could be high risk of bias. Acknowledge snowball sampling bias.

Add a paragraph on data cleaning and missing data handling.

Small sample =58 limits power; 2 medical students included dilutes the physician-only analysis. Add justification for sample size (power analysis…).

No multivariate regression. Univariate analysis overstates findings; confounders are uncontrolled.

Mean PHQ/IES-R scores not reported. Provide means and SDs for PHQ-4 and IES-R-Gr.

Table 2 title. Typo “COVID-18 pandemic”

Report Cronbach’s α for the current dataset.

Tables 3, table 4 are overcrowded; specify significant findings.

Narrative repetition: The text prior to all tables duplicated the table content instead of interpreting it. Trimming is needed.

Discussion has cross-country comparison; cites relevant Greek and international studies. However, it is overly descriptive; limited theoretical analytical depth. Discussion conflates association with causation.

Missing exploration of protective factors such as social support, workplace culture..

Inconsistent comparisons: sometimes uses “agree/disagree” but doesn’t explain why.

Weak critical reflection on sample limitations and possible self-selection of distressed participants.

Integrate moral distress literature from early introduction back into discussion for theoretical coherence.

Clarify policy implications such as national physician support programs, post-crisis recovery frameworks….

Conclusions overstate evidence given sample limitations.  consider: “preliminary findings suggest a concerning prevalence…” and call for larger, longitudinal studies.

References are comprehensive.

Consider adding a flow diagram of participant recruitment and exclusion. Include a bar chart or forest plot summarizing ORs for mental health outcomes.

Results 3.1.  typo“did not had dependents” => “did not have dependents”

Results 3.2.   “mean 28.56 ± 29.32 hours per week” ?

Discussion page 9 “may not ne generalizable” => “may not be generalizable”

“Nonetheless the results highlight…” => “Nonetheless, the results…”

Author Response

We sincerely thank the Reviewer for the careful evaluation of our manuscript

Author Response File: Author Response.docx

Reviewer 3 Report

Dear Author(s),

thank you for submitting your manuscript, “Association of the COVID-19 Pandemic with Greek Physicians’ Mental Health Symptoms” to COVID. This manuscript explores the psychological outcomes of Greek physicians during the COVID-19 pandemic, focusing on anxiety, depression, and PTSD symptoms measured through validated instruments. The topic is of ongoing relevance, as the effects of the pandemic on healthcare workers remain a global concern. However, the current version requires refinement before it can be considered for publication.

Conceptually, the link between moral distress and mental health outcomes needs to be articulated more coherently to support the study's focus. Methodologically, the sampling strategy, eligibility criteria, and inclusion of medical students need clarification. The Methods section lacks structural clarity, and the Discussion does not adequately highlight the study’s originality in relation to previous, larger scale research. Finally, the language and presentation of results would benefit from editing for precision and conciseness.

Abstract

1. The abstract should include the study design (cross-sectional survey) and a brief mention of the recruitment process.
2. Quantitative findings (prevalence rates and significant associations) are reported, but confidence intervals could enhance interpretability.

Introduction

1. The introduction provides a contextual overview, citing relevant challenges faced by physicians during the COVID-19 pandemic. However, the examination of moral distress and moral trauma feels conceptually disconnected from the study’s main focus on mental health outcomes (anxiety, depression, PTSD). Clarify the theoretical linkage: moral distress can lead to moral injury, a form of deep psychological harm associated with mental health outcomes such as anxiety, depression, and PTSD. This connection should be made explicit, supported by recent literature (e.g., https://doi.org/10.1177/09697330241281376).
2. The novelty of this study is unclear. Similar Greek studies (cited after in the Discussion section) have already investigated mental health outcomes among healthcare workers during the COVID-19 pandemic (1: https://doi.org/10.3390/ijerph18052390; 2: https://doi.org/10.2478/jccm-2020-0042; 3: https://doi.org/10.1037/tra0000914). The authors should emphasize what differentiates this work, improving the rationale for performing such research.
3. The rationale and study aim should be stated concisely, in hypothesis oriented form (e.g., “to assess post-pandemic prevalence of anxiety, depression, and PTSD among physicians and examine their association with occupational and health related factors”).

Materials and Methods

1. Structure: Please divide the section into clear sub-sections: Study design, Sample and sampling procedure, Instruments, Data analysis, and Ethical considerations. Avoid merging unrelated content (for example, ethical statements with instrument descriptions).
2. Sampling and Recruitment:
   • The recruitment process needs greater transparency. Did you adopt a convenience or purposive sample strategy? Please make it explicit.
   • Clarify how many institutions were involved and how potential participants’ email addresses were obtained.
   • Explain why 200 potential participants were invited, and not a larger number, given the expected low response rate typical of online surveys.
   • State how eligibility was verified: did participants self-certify? The online questionnaire included a screening form?
   • The text indicates participation through “personal acquaintances,” which may introduce bias; this should be acknowledged as a limitation.
3. Participants:
   • The statement about “58 eligible individuals participated (response rate 29%), of whom 56 were physicians and two were medical students” belongs in the Results, not the Methods.
   • The inclusion of two medical students is inconsistent with the stated inclusion criteria. This introduces a confounding element, as students experience different stressors (e.g., academic pressure) unrelated to frontline work. Their inclusion should be justified or reconsidered; if retained, it must be discussed as a limitation of the study.
4. Presentation and Flow:
   • The paragraph describing the distribution of participants across institutions reports results and should be moved accordingly.
   • The paragraph beginning “The data were stored and processed…” merges ethical and methodological details; these should be separated.
5. Instruments:
   • The use of PHQ-4 and IES-R-Gr is appropriate. Consider providing internal reliability coefficients (Cronbach’s α) for your sample.
   • The psychometric discussion is overly detailed; summarize key points and cite the validation studies briefly.
6. Ethical Considerations:
   • The ethical approval is stated. Add brief clarification on how anonymity and data protection were ensured (e.g., access to data, storage location, and duration).

Results

• The results are generally organized but verbose. Consider condensing descriptive statistics and emphasizing key findings.
• Consider reorganizing the results into three concise subsections: (1) Participant Characteristics, (2) Mental Health Outcomes, (3) Factors Associated with Outcomes.
• Report confidence intervals for prevalence rates.
• Ensure that subgroup analyses are presented with caution, as some categories (e.g., laboratory staff) are too small to draw firm conclusions.

Discussion

• The discussion appropriately references Greek and international studies, but the narrative could be more analytical and less descriptive.
• Begin with a summary of the main results before interpreting them.
• Avoid restating literature extensively; focus instead on how this study’s findings compare or contrast with previous evidence.
• The link between moral distress and mental health should be revisited to ensure conceptual coherence with the introduction.
• Discuss the potential impact of shortages of materials and ethical dilemmas on psychological well-being.
• The limitations section currently appears as a short paragraph. It should be expanded and formatted as a distinct subsection. Explicitly acknowledge: 1) Small sample size and limited generalizability; 2)Convenience sampling and recruitment bias via acquaintances; 2) Low response rate (29%); 3) Inclusion of two medical students; 4) Self-report bias; 5) Cross-sectional design; 6) Lack of pre-pandemic baseline data.

Conclusions

• The conclusions should more accurately reflect the descriptive nature of the study, avoiding causal claims (e.g., “due to the circumstances they faced during the COVID-19 pandemic”).
• Avoid broad policy statements beyond the scope of the findings.

Language and Style

• The English language is understandable but requires editing to improve fluency and avoid awkward phrasing.
• Some expressions (e.g., “none working in a laboratory developed any mental health symptoms”) should be rephrased for academic tone.
• Check for minor typographical issues and maintain uniform style throughout (e.g., spacing around parentheses, consistent capitalization).

Overall Recommendation

The manuscript contributes valuable insight into the mental health of Greek physicians following the COVID-19 pandemic. However, major revisions are required to clarify conceptual foundations, improve methodological rigor, and refine the presentation. Addressing the concerns outlined above will enhance the scientific quality and credibility of the work.

I hope these comments are constructive and helpful to the Author(s).

Best Regards.

Author Response

We sincerely thank the reviewer for the careful evaluation of our manuscript

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

The authors responded adequately all of my comments, I have no further comments. 

 I think the manuscript is improved now. No further comments. 

Author Response

Dear Reviewer

we sincerely thank you for your valuable comments

Reviewer 3 Report

Dear Author(s),

Thank you for resubmitting your manuscript, renamed “Mental health outcomes among physicians following COVID-19 pandemic” to COVID.

The manuscript shows improvement following the revisions made in response to the previous review. The structure is clearer, the conceptual framework more coherent, and the reporting of methods and results more transparent. However, some issues still require attention before the paper can be considered for publication.

Introduction

1. The inclusion of the concepts of moral distress and moral injury, along with the appropriate reference, is appreciated. However, the paragraph ends with a sentence that appears misplaced or automatically generated: “Moral distress can lead to moral injury, a form of deep psychological harm associated with mental health outcomes such as anxiety, depression, and PTSD. This connection should be made explicit, supported by recent literature [9].” The last phrase (“This connection should be made explicit…”) should be deleted, as it reads like an editorial note rather than part of the manuscript text.
2. At the end of the Introduction, the statement “To date, no studies have systematically examined the persistence of anxiety, depression, and PTSD symptoms among Greek physicians using validated instruments post-pandemic” is overly categorical and slightly awkward in English. Please rephrase as: “To the best of our knowledge, no studies have yet systematically examined the persistence of anxiety, depression, and PTSD symptoms among Greek physicians post-pandemic using validated instruments.”

Materials and Methods

1. Sample and Sampling Procedure: The authors appropriately clarified the sampling strategy, but the current phrasing (“The sampling method used was the snowball sampling, which of course induces some bias”) mixes methodological description with interpretation. Discussion of potential bias should be reserved for the Limitations section, not for Methods. Please rephrase this part to report only the procedures used.

Results

1. In Section 3.1 (“Participant Characteristics”), two medical students remain included in the analysis. As noted in the previous review, this inclusion conflicts with the stated eligibility criteria in Section 2.1 (“Study Design”), where participants were defined as “Physicians working as frontline staff…”. Since medical students are not physicians, this introduces a potential bias. I recommend one of the following actions:
   a) If the recruitment process through the Medical Association explicitly included students, please clarify this in the eligibility criteria and justify their inclusion.
   b) Otherwise, remove these two participants from the dataset, as they do not fit the defined study population.
2. In the same section 3.1 and Table 1, the variable “dependents” is reported but not explained. The meaning is ambiguous: does this refer to family members, children, or professional subordinates? Please clarify this definition, as in most healthcare systems, “dependents” would not apply to professional hierarchies (e.g., nurses, technicians).

Discussion

1. The statement “The physicians working in the laboratory did not develop any mental health symptoms” appears twice (end of page 11 and again on page 12). Please merge these sentences to avoid repetition.
   Additionally, there is an inconsistency: Section 3.1 states that “The laboratory staff has been taken out from the analysis due to zero events in some categories.” If laboratory physicians were excluded from the analysis, they should not be discussed as a subgroup in the Discussion. Please clarify this discrepancy for internal consistency between the Results and Discussion sections.

Language and Style

• The English language requires further professional editing to improve fluency and avoid awkward phrasing or typographical errors (e.g., “stuff” should be “staff”; “alsos” should be “also”).
• Table formatting remains inconsistent and should be reviewed carefully for alignment, numbering, and presentation.

Overall Recommendation

This manuscript provides insights into the mental health outcomes of Greek physicians following the COVID-19 pandemic and addresses an important research gap. The authors have made progress since the previous submission. However, revisions are still required to ensure conceptual precision, methodological consistency, and linguistic clarity.

Addressing the points above will significantly strengthen the manuscript’s scientific rigor and readability.

I hope these comments are constructive and assist the authors in refining their work.

Best regards.

Author Response

We thank the reviewer for his valuable comments. We have revised our manuscript accordingly

Author Response File: Author Response.docx