Review Reports - Clinical and Psychological Disturbances of Myasthenia Gravis: How Anxiety, Sleep Quality, and Thymectomy Interact

Round 1

Reviewer 1 Report

Thank you for the opportunity to review your manuscript.

The study presented in this manuscript was designed to assess depression, anxiety, sleep problems, and fatigue in 16 individuals with MG and to analyse the relationships among these variables, as well as to determine the influence of corticosteroid use and thymectomy. The theme itself fits the scope of the Psychology International.

However, it has some flaws, particularly due to the fact that this study presents an insufficient theoretical rationale, considering the number of variables under analysis. Furthermore, the sample size is small, given the psychological variables studied.

Title: Please, I suggest that the title needs to be revised, because does not accurately represent the study conducted. I suggest, for example: "Clinical and Psychological Disturbances of Myasthenia Gravis: how Anxiety, Sleep Quality, and Thymectomy Interact".

Keywords: Please, change keywords. Keywords cannot be the same as the title.

Literature review: Please, include, after the introduction section, a section with a more extensive literature review.

Results: Please, review all verbs, putting them in the past.

Author Response

Firstly, we would like to thank the reviewer for his/her valuable suggestions. We would like to add, however, that we have some doubts regarding certain comments. For example, regarding the sample size, which does not match with the data presented in the article. Additionally, we would like to mention that a native English speaker has reviewed the language, and some changes have been incorporated for clarity and fluency. The suggested revisions are described below, with each change addressed point-by-point. After each suggestion, the answer is written in italic.

Thank you for the opportunity to review your manuscript. The study presented in this manuscript was designed to assess depression, anxiety, sleep problems, and fatigue in 16 individuals with MG and to analyse the relationships among these variables, as well as to determine the influence of corticosteroid use and thymectomy. The theme itself fits the scope of the Psychology International.

Comment 1: However, it has some flaws, particularly due to the fact that this study presents an insufficient theoretical rationale, considering the number of variables under analysis. Furthermore, the sample size is small, given the psychological variables studied.

As myasthenia gravis is a rare disease, recruitment of a large sample size is inherently challenging. Studies often operate with smaller sample sizes due to the limited number of eligible participants, as is common in rare disease research. For instance, as noted in the systematic review and meta-analysis by Nadali et al. (2023) on the prevalence of depression and anxiety in MG patients, studies such as those by Vitturi et al. (2021), with 49 participants, and Gavrilov et al. (2020) with 73 have been able to address these psychological aspects despite operating with relatively small sample sizes. These examples highlight that smaller sample sizes are typical in this type of research, and our study's sample size is consistent with the challenges faced in recruiting participants for rare diseases. Furthermore, the limitations that this sample size may cause at the analytical level are mentioned in the limitations section of the studies.

References

Nadali J, Ghavampour N, Beiranvand F, Maleki Takhtegahi M, Heidari ME, Salarvand S, Arabzadeh T, Narimani Charan O. Prevalence of depression and anxiety among myasthenia gravis (MG) patients: A systematic review and meta‐analysis. Brain and Behavior 2023, 13(1), e2840. https://doi.org/10.1002/brb3.2840
Vitturi, B. K., Kim, A. I. H., Mitre, L. P., Pellegrinelli, A., & Valerio, B. C. O.(2021). Social, professional and neuropsychiatric outcomes in patients with myasthenia gravis. Neurological Sciences, 42(1), 167–173. https://doi.org/10.1007/s10072-020-04528-w
Gavrilov, Y. V., Alekseeva, T. M., Kreis, O. A., Valko, P. O., Weber, K. P., & Valko, Y. (2020). Depression in myasthenia gravis: A heterogeneous and intriguing entity. Journal of Neurology, 267(6), 1802–1811. https://doi.org/10.1007/s00415-020-09767-7

Comment 2: Title: Please, I suggest that the title needs to be revised, because does not accurately represent the study conducted. I suggest, for example: "Clinical and Psychological Disturbances of Myasthenia Gravis: how Anxiety, Sleep Quality, and Thymectomy Interact".

Thank you for your suggestion regarding the title. We agree that the original title did not fully capture the scope of the study. We found the proposal interesting and the new title is: "Clinical and Psychological Disturbances of Myasthenia Gravis: How Anxiety, Sleep Quality, and Thymectomy Interact."

Comment 3: Keywords: Please, change keywords. Keywords cannot be the same as the title.

We have revised keywords as suggested. The keywords now are:

Myasthenia gravis, psychological impact, sleep impairment, fatigue, emotional wellbeing.

Comment 4: Literature review: Please, include, after the introduction section, a section with a more extensive literature review.

Thank you for your suggestion to include a literature review section. We have included a comprehensive literature review within the Introduction section, in line with the structure of the journal. This approach, while adhering to the journal's guidelines, allows us to provide a comprehensive background and context for our study.

Comment 5: Results: Please, review all verbs, putting them in the past.

Thank you for your suggestion. These sentences have been revised

Reviewer 2 Report

The manuscript investigates the psychological and clinical disturbances in Myasthenia Gravis: Relations with Anxiety, Sleep Quality, and Thymectomy. This study is significant since it has global health implications and addresses mental health problems. Very nice and clear introduction section with credible sources. The introduction provides sufficient background information and clearly states the study’s importance; however, other sections need improvement, and feedback is provided in the below section.

Here are details suggestions to improve this menuscript for publication in this journal:
The methods section is not very clear, which starts with the sample, but the writing of the sample section starts with the research design term—cross-sectional research. So I would suggest you to follow some research methods writing guidance, i.e., study design, study population, sample size and sampling techniques, data collection methods, data collection tools/instruments, data analysis, and ethical considerations, which are basic and key to adhering to any quantitative research.
Table 1 is your findings, so this table should be presented under Section 3 but not in the Methods sections.
Please also provide a brief description of who those control participants are, how they are comparable with the clinical group, and how you selected and recruited them, which is not clearly stated in the current version.
Statistical value presentation usually avoids presenting 0.000, which is recommended to present <0.001. So look at the entire manuscript and make appropriate corrections.
Can you add a sub-section under the discussion about the strengths and limitations of the study?
The authors talk about the small sample size as one of the limitations but could not talk about the purposive sampling techniques, self-reporting tools, which should also be clearly articulated, and how you controlled the bias.
Nicely articulated the conclusion, but what are the recommendations to the policy levels, practitioners, and researchers that should also be highlighted at the end of the conclusion section?
Check the reference list where we can see – instead of. signs after number i.e., 1-, 2-..
Check and make consistency of your reference list. Journal title: all first alphabet capital or capital and small, i.e., 3 vs. 4.

Author Response

First of all, we would like to thank reviewer for her/his helpful suggestions. We are sure that these changes will contribute to the improvement of the paper. The suggested revisions are described below, mentioning point-by-point what changes have been made. After each suggestion, the answer is described written in italic.

The manuscript investigates the psychological and clinical disturbances in Myasthenia Gravis: Relations with Anxiety, Sleep Quality, and Thymectomy. This study is significant since it has global health implications and addresses mental health problems. Very nice and clear introduction section with credible sources. The introduction provides sufficient background information and clearly states the study’s importance; however, other sections need improvement, and feedback is provided in the below section.

The methods section is not very clear, which starts with the sample, but the writing of the sample section starts with the research design term—cross-sectional research. So I would suggest you to follow some research methods writing guidance, i.e., study design, study population, sample size and sampling techniques, data collection methods, data collection tools/instruments, data analysis, and ethical considerations, which are basic and key to adhering to any quantitative research.

We agree with the reviewer’s observation and appreciate the suggestion to improve the clarity of the methods section. In response, we have revised the structure, have begun with the study design and added the following paragraph (linen 86-89):

“A cross-sectional research study was carried out using convenience sampling. Data were collected from two different groups: a clinical group of patients with a diagnosis of MG and a healthy control group at a single point in time. Participants were recruited based on their accessibility and willingness to participate.”

Moreover, a new section title has been added “Ethical considerations” at line 167.

Table 1 is your findings, so this table should be presented under Section 3 but not in the Methods sections.

Thank you for the suggestion. We have removed Table 1 from the Participants section and relocated it to the Results section, as recommended.

Please also provide a brief description of who those control participants are, how they are comparable with the clinical group, and how you selected and recruited them, which is not clearly stated in the current version.

Thank you for this observation. In response, we have clarified the selection process for the control group in line 95-98.

“The rest of the sample were healthy volunteers without this pathology. They were matched to the clinical group for age, years of education and sex. This matching allowed more accurate comparisons between the groups.”

Statistical value presentation usually avoids presenting 0.000, which is recommended to present <0.001. So look at the entire manuscript and make appropriate corrections.

Thank you for the suggestion. We have reviewed the entire manuscript and made the necessary corrections, replacing any instances of 0.000 with <0.001, as recommended.

Can you add a sub-section under the discussion about the strengths and limitations of the study?

We have added a sub-section under the discussion that addresses the strengths and limitations of the study (line 305).

The authors talk about the small sample size as one of the limitations but could not talk about the purposive sampling techniques, self-reporting tools, which should also be clearly articulated, and how you controlled the bias.

Thank you for your comment. In response, we have revised the limitations section to clearly articulate the use of convenience sampling, the reliance on self-reporting tools, and how we controlled for potential bias (line 301-323).

“Despite the significant findings of this study, several limitations should be acknowledged. First, the sample size is relatively small, which is common in rare dis-ease research and may affect the robustness of statistical analyses and limit the generalizability of the results.

Another limitation is the cross-sectional design. This provides only a momentary description of the sociodemographic and clinical characteristics of the participants, without establishing a causal relationship. A longitudinal study could better examine the long-term effects of treatments such as thymectomy on disease progression and quality of life, and clarify whether observed associations persist over time or are transient. In addition, although the study takes into account the treatments received, an extension of the list of drugs included could provide a deeper insight into the effects of treatment.

Finally, the study used convenience sampling, recruiting participants mainly from associations and hospitals in Spain and Latin America. Although efficient, this method may introduce selection bias and limit the generalizability of the results.

Despite these limitations, this study provides useful information about the experience of people affected by MG. Additionally, it includes both a clinical group of patients with MG and a control group. This allows meaningful comparisons between the two groups while controlling for important socio-demographic factors such as age, gender and education. The inclusion of participants from both Spain and Latin America increases the diversity of the sample. This makes the findings more relevant to a broad, Spanish-speaking population. These strengths contribute to the study's comprehensive approach to understanding the clinical and psychosocial aspects of MG, providing important insights for future research and clinical practice.”

Nicely articulated the conclusion, but what are the recommendations to the policy levels, practitioners, and researchers that should also be highlighted at the end of the conclusion section?

Thank you for your comment. In response, we have added a paragraph to the conclusion section in lines 335-341.

“By considering both the physical and psychological components of the disease, the specialists can offer more comprehensive care that improves patient outcomes. Moreover, these findings underscore the importance of incorporating psychological assessments and interventions as part of routine care for MG patients. Future research should explore the long-term effects of treatments on mental health and investigate the mechanisms linking anxiety, sleep disturbances, and fatigue, to develop more targeted interventions for improving quality of life in this patient population.”

Check the reference list where we can see – instead of. signs after number i.e., 1-, 2-..

We have reviewed and corrected the reference list to replace the "-" signs with the proper numerical formatting (i.e., 1., 2., etc.) as per the required style.

Check and make consistency of your reference list. Journal title: all first alphabet capital or capital and small, i.e., 3 vs. 4.

We have reviewed the reference list and ensured that the journal titles are consistently formatted according to the appropriate style guide.