Challenges in Managing Depression in Clinical Practice: Result of a Global Survey

Dear Author, thank you for the opportunity to review your manuscript entitled “Challenges in managing depression in clinical practice: result of a global survey”, which explores the important topic of managing depression. Your research has the potential to contribute to our understanding of this issue, and I appreciate the effort you have put into this study.

While reviewing your manuscript, I identified a few areas that require further attention and improvement.

Thanks very much for your detailed review and observations.

Comment (1) In the introduction, the author emphasizes the importance of this problem by clearly describing the prevalence, comorbidities, and treatment of depression. However, it would be better review previous related work on this issue. Especially, it is best for the author to clearly point out the limitations of previous research and the novelty of this study, providing sufficient basis for the formulation of research questions.

Response 1 Thanks. In the revised draft the introduction has been updated, that there are hardly similar survey of psychiatrists covering various countries on a range of issues from missed diagnoses to inadequate response. Further references have been given.

Comment (2) I don't quite understand how the data in the results section was obtained, as the survey targets doctors rather than patients and hospital management departments.

Response (2). The data is based on the response of the psychiatrists, specifically their experience managing depression in their own clinics. It was intended to capture the difficulties they face in managing depression. They were asked specific questions about the management approaches and the outcome using questionnaire and their responses formed the basis of the results. Further details are given in the methodology section. 

Comment (3) It would be better to provide a more detailed and specific description of the limitations of this study.

Response (3). The limitations have been updated in the revised draft.

Comment (4) Lastly, I noticed that the conclusions section is lengthy. I recommend revising and tightening the content to improve clarity and conciseness.

Response (4). Thanks. The conclusion in the revised draft has been made more condensed.

Comment (5). Despite these concerns, I believe this study has the potential to make a valuable contribution to the field. I hope you find these comments and suggestions helpful in revising your manuscript. I wish you the best in your future research endeavors.

Response (5). Thanks very much.

Comment (1).

Despite improvements in knowledge and interventions, many patients with depression remain undertreated-treatment-discontinuation and nonresponse are common. To explore challenges faced by clinicians in managing depression in clinical practice and uncover suggestions for potential solutions, the author surveyed psychiatrists online about the challenges in managing depression in clinical practice. aiming to identify factors influencing the treatment of depression. There is a wealth of data obtained from the survey, and some of the information should be very helpful to clinicians and researchers in managing and understanding depression. The paper is well written and references are appropriately cited.

Response 1.

Thanks very much for your observations.

Comment 2

Table 1 “There were 137 responses from the 18 countries, 70 (51.1%) from HIC and 67 (48.9%) 119 from low and middle income countries (LAMIC).” Detailed information regarding the survey should be provided in the supplemental data. “It was an online survey based on a pre-designed questionnaire.” What are these questions?

Response 2.

Thanks. The summary of all the questions is given in the methodology section (4.4).

Comment 3

Table 2. What factors could explain the percentage differences in management strategies adopted by HIC and LAMIC?

Response 3.

Thanks very much. This is an important area for reflection. The draft has been revised with this information now.

Comment 4

Table 3 In addition to medication, there are other strategies that can help manage bipolar depression, such as family-centered therapy, mindfulness practices, and social connection.

Response 4.

Thanks very much. The results showed around 29% respondents mentioned about psychotherapy for bipolar depression. The draft has been revised in the Discussion section, and included the effective therapies with additional references.

Comment 5

Table 4 Why is sedation as a challenge to treatment continuity twice as high in HIC as in LAMIC (30 (44.8%) vs 15 (21.4%))?

Response 5

Thanks for highlighting this aspect. This is probably because of increased benzodiazepine and additional medication use in LAMIC; the result suggested that there was a significant difference in LAMIC where 53.8% use benzodiazepines in contrast to 27.3% in HIC and no additional medication in 6.2% v 27.3% respectively (p < 0.005). It has now been discussed further.  

Comment 6

Table 5 Is there overlap between different rows? For example, are there patients with both “nonadherence” and “physical comorbidities”?

Response 6

Thanks. These are the responses from the clinicians about the challenges maintaining the continuity of care. It’s not about individual patients’ information. The rows are discrete variables, and the proportions depict the proportions of respondents mentioned these challenges. Clinicians mentioned multiple challenges and the most common ones are mentioned here.   

Comment 7.

Table 6 In many cases of depression, the cause is hereditary, while others seem unrelated to genes (psychological or physical factors). Are the solutions to depression different between those caused by genetics and those caused by other nongenetic factors?

Response 7

Thanks very much. Although the causes of depression vary widely, and can be multiple in individual cases, the approaches of intervention are similar which include psychotherapies, medications, and appropriate social support irrespective of causes. However the focus and intensity of the particular treatment approach may vary depending upon the severity of the depression and associated contributing factors.