COVID-19 and Psychological Impact

Round 1

Reviewer 1 Report

This is a very important study to consider the impact of the COVID-19 pandemic on public health.

1. The authors described information on each study in the text. However, it would be more informative and helpful for readers if authors make tables showing brief details of each study cited (e.g., author, country, number of cases per population or rates, etc).
2. Prepare Conclusion and Prospects in the format of paragraphs, instead of numbered items. 

Author Response

Dear Reviewer1, 

many thanks for taking the time to review and provide feedbak on my manuscript. I have found your two suggestions very useful. First, I followed your suggestion of reporting and writing rather than listing the conclusions. Please, see the corresponding section in the manuscript. You also suggested to produce a table with the most relevant results of each section. I have carefully think about this suggestion because it is true that, being and entry, it would ease the reading. However, as it could also become outdated very soon due to the rapid publishing flow in this area, I have included a table (please, see Table 1) but only containing the most relevant conclusions of each section. The reason is that this information, as I already acknowledged in the manuscript, is "unperishable", and therefore will skip the outdating problem. I hope that these two modifications satisfy your enquiries about the manuscript.

I would also like to add that I have made two else modifications. First, I have included a brief reference to the post-intensive care syndrome in the Covid-19 infection section, since I have found to be very much mentioned lately with regards to cognitive impairment after COVID-19 infection and therefore I had considered that is was relevant to appear in the entry (see lines 275-283): 

"Importantly, survivors of Intensive Care Units (ICU) may also experience post-intensive care syndrome (PICS) some months after discharge, which may include a vast array of symptoms collectively grouped into physical impairment, cognitive impairment, and mental health problems. Since COVID-19 can entail ICU hospitalization, a recent review has warned about the prevalence of symptoms associated to PICS in COVID-19 patients, reaching high rates of psychological impact: 20–57% pertaining to cognitive impairments, and 6–60% pertaining to mental health problems after 1–6 months after discharge [45]. Therefore, further research in psychological impact of COVID-19 may also consider the study of PICS in discharged COVID-19 patients as well as in their relative carers"

Finally, according to Reviewer 2's feedback, I have also included a paragraph in the shape of a brief discussion about the different methodologies that the published studies have and how they can provide different information about the psychological impact of COVID-19 (transversal, longitudinal, prospective). Please, see lines 317-343:

"Finally, it is important to note that most of the studies included in the systematic reviews commented so far followed a cross-sectional methodology, namely, they described the mental state of the population in their samples in a certain point of time, therefore not allowing to provide causal or longitudinal knowledge, but inferential. These studies are relevant because they are descriptive of an unprecedent health crisis in recent History. However, it is also very informative to look at longitudinal studies because they can provide baseline levels (before the pandemic outbreak) to be compared to pandemic levels, so that the potential significant differences found can be less doubtlessly attributed to the effects of the pandemic. These studies are scarce because they imply both a periodic interest in monitoring the mental health of population and some reserved budget devoted to the assessment task. At this respect, official national reports about mental health are one eligible piece of evidence, since they provide longitudinal data at different waves in large samples and they are usually freely available (e.g., see UK report about mental distress: it increased from 18·9% (95% CI 17·8–20·0) in 2018–19 to 27·3% (26·3–28·2) in April, 2020) [46]. Also, prospective studies collecting data at several points during a certain period can be very informative. Concretely, by measuring the mental health during different moments along the COVID-19 pandemic period, the potential long-term psychological symptoms, or cumulative consequences of certain subgroups of population, such as health care workers, can be revealed (e.g., this study [47] collected data during three COVID-19 waves: April-May 2020, December 2020, and April-May 2021 and was able to conclude that there was an elevated frequency of anxiety, an increasing prevalence of depression, and active thoughts of leaving their jobs in Italian health-workers). Thus, the methodology of the studies is crucial to carefully conclude about the psychological impact related to COVID-19 depending on our interest (i.e., describing, comparing, foreseeing). Indeed, future studies about psychological impact should consider these interests to look for previous data (and produce longitudinal data) or to propose different measurement points (and produce repeated cross-sectional data)."

Many thanks for your time. I am looking forward to your response. 

Reviewer 2 Report

The text is written in a concise and clear way. The author has the correctness to warn readers that, given a large number of studies in progress, the content will soon be out of date. He should also warn readers that the thousands of articles written on the subject are nearly all cross-sectional. The abundance of research has also made it possible to produce several systematic reviews and meta-analyses. All the studies retrieved in these reviews, however, were cross-sectional. Depressive symptoms and anxiety in HCWs were compared to “normal values”, administrative staff, or external samples; moreover, some studies had no control group. Some studies had negative results. Overall, these reviews produced little evidence of an increase in mental health problems during the outbreak. The author should rather cite longitudinal or prospective studies. The following references could better frame the research in the context of the literature: Magnavita N, Soave PM, Antonelli M. Prolonged Stress Causes Depression in Frontline Workers Facing the COVID-19 Pandemic-A Repeated Cross-Sectional Study in a COVID-19 Hub-Hospital in Central Italy. Int J Environ Res Public Health. 2021 Jul 8;18(14):7316. doi: 10.3390/ijerph18147316.--- Magnavita, N.; Soave, P.M.; Antonelli, M. A One-Year Prospective Study of Work-Related Mental Health in the Intensivists of a COVID-19 Hub Hospital. Int. J. Environ. Res. Public Health 2021, 18, 9888. https://doi.org/10.3390/ijerph18189888.

Please note that it is not mandatory that the author cites these specific articles and he is welcome to seek alternative manuscripts in the literature that are relevant to the manuscript’s content.

Author Response

Dear Reviewer 2, 

many thanks for taking the time to review and provide feedback on my manuscript. I need to recognise that your response made me think during a while. Please, find below my response to each of your suggestions:

The text is written in a concise and clear way. The author has the correctness to warn readers that, given a large number of studies in progress, the content will soon be out of date.

Many thanks.

He should also warn readers that the thousands of articles written on the subject are nearly all cross-sectional. The abundance of research has also made it possible to produce several systematic reviews and meta-analyses. All the studies retrieved in these reviews, however, were cross-sectional.

I agree with the Reviewer that this methodological warning is indeed very relevant for this topic. Importantly, I have not included more references of these types of studies in the rest of the entry because I found them to be very scarce in the literature, so they would not be representative of general population but circumscribed to specific countries. However, as I agree that the methodological reference was needed to be better described in the entry, I decided to include both a first mention at the beginning of the entry, where I describe the type of studies to be considered in the entry (see lines 32-39):

Importantly, given the overwhelming number of studies, a broaden vision has been prioritized by selecting systematic reviews, meta-analysis and longitudinal research over transversal or nation-specific studies, whenever possible. However, this strategy does not ensure the provision of causal nor relational knowledge given the fact that most of the studies conducted and published so far are cross-sectional (i.e., measuring a specific population group in a specific point of time) rather than longitudinal (i.e., gathering several measures of a specific population group along a period of time) or prospective (i.e., starting the data collection before the pandemic outbreak, which may count as a baseline, and continuing afterwards, to allow for comparisons), and therefore even systematic reviews may be biased in their conclusions.

and also an entire paragraph at the final section of the entry (see lines 317-343). In this final paragraph I describe transversal, longitudinal and repeated cross-sectional methodologies and discuss what information related to the psychological impact of COVID-19 can be extracted from them and how further studies should consider to employ those methodologies. Thus I could introduce one of the references you shared, from Italy, and another reference I found in UK (see lines 317-343):

"Finally, it is important to note that most of the studies included in the systematic reviews commented so far followed a cross-sectional methodology, namely, they described the mental state of the population in their samples in a certain point of time, therefore not allowing to provide causal or longitudinal knowledge, but inferential. These studies are relevant because they are descriptive of an unprecedent health crisis in recent History. However, it is also very informative to look at longitudinal studies because they can provide baseline levels (before the pandemic outbreak) to be compared to pandemic levels, so that the potential significant differences found can be less doubtlessly attributed to the effects of the pandemic. These studies are scarce because they imply both a periodic interest in monitoring the mental health of population and some reserved budget devoted to the assessment task. At this respect, official national reports about mental health are one eligible piece of evidence, since they provide longitudinal data at different waves in large samples and they are usually freely available (e.g., see UK report about mental distress: it increased from 18·9% (95% CI 17·8–20·0) in 2018–19 to 27·3% (26·3–28·2) in April, 2020) [46]. Also, prospective studies collecting data at several points during a certain period can be very informative. Concretely, by measuring the mental health during different moments along the COVID-19 pandemic period, the potential long-term psychological symptoms, or cumulative consequences of certain subgroups of population, such as health care workers, can be revealed (e.g., this study [47] collected data during three COVID-19 waves: April-May 2020, December 2020, and April-May 2021 and was able to conclude that there was an elevated frequency of anxiety, an increasing prevalence of depression, and active thoughts of leaving their jobs in Italian health-workers). Thus, the methodology of the studies is crucial to carefully conclude about the psychological impact related to COVID-19 depending on our interest (i.e., describing, comparing, foreseeing). Indeed, future studies about psychological impact should consider these interests to look for previous data (and produce longitudinal data) or to propose different measurement points (and produce repeated cross-sectional data)."

The response to the rest of your comments are included in my previous responses.

I would also like to add that two more issues. First, Reviewer 1 suggested to produce a table with the most relevant results of each section. I have carefully thought about this suggestion because it is true that, being and entry, it would ease the reading. However, as it could also become outdated very soon due to the rapid publishing flow in this area, I have included a table (please, see Table 1) but only containing the most relevant conclusions of each section. The reason is that this information, as I already acknowledged in the manuscript, is "unperishable", and therefore will skip the outdating problem.

Second, I have also included a brief reference to the post-intensive care syndrome in the Covid-19 infection section, since I have found to be very much mentioned lately with regards to cognitive impairment after COVID-19 infection and therefore I had considered that is was relevant to appear in the entry (see lines 275-283): 

"Importantly, survivors of Intensive Care Units (ICU) may also experience post-intensive care syndrome (PICS) some months after discharge, which may include a vast array of symptoms collectively grouped into physical impairment, cognitive impairment, and mental health problems. Since COVID-19 can entail ICU hospitalization, a recent review has warned about the prevalence of symptoms associated to PICS in COVID-19 patients, reaching high rates of psychological impact: 20–57% pertaining to cognitive impairments, and 6–60% pertaining to mental health problems after 1–6 months after discharge [45]. Therefore, further research in psychological impact of COVID-19 may also consider the study of PICS in discharged COVID-19 patients as well as in their relative carers"

Thanks for your time in revising these comments. I hope these modifications satisfied your enquiries about this entry. Best.

Round 2

Reviewer 1 Report

I don't have further questions.

Reviewer 2 Report

The manuscript has been sufficiently improved