Reference: manuscript BPSY-D Treatment adequacy of anxiety disorders among young adults in Finland

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1 Author s response to reviews Title: Treatment adequacy of anxiety disorders among young adults in Finland Authors: Teija Kasteenpohja (teija.kasteenpohja@thl.fi) Mauri Marttunen (mauri.marttunen@thl.fi) Terhi Aalto-Setälä (terhi.aalto-setala@kela.fi) Jonna Perälä (jonna.perala@hus.fi) Samuli Saarni (samuli.saarni@helsinki.fi) Jaana Suvisaari (jaana.suvisaari@thl.fi) Version: 1 Date: 14 Oct 2015 Author s response to reviews: To: Dr. Sharon Lawn, Editor, BMC Psychiatry Reference: manuscript BPSY-D Treatment adequacy of anxiety disorders among young adults in Finland October

2 Dear Editor, Thank you for your kind and for the valuable comments by the reviewers. Please find enclosed our manuscript Treatment adequacy of anxiety disorders among young adults in Finland (BPSY-D ), which we resubmit for consideration for publication as an original article in the BMC Psychiatry. We have taken into account the comments by reviewers Jeffrey Strawn and Rachel Jenkins and revised the paper accordingly. We thank reviewers for their excellent comments. In our response to reviewers, we reply to the comments of the reviewers and explain the revisions we have made. Additions and changes in the manuscript have been marked in boldface and italic. If needed, we will be happy to modify the manuscript further. Thank you for your attention and consideration. We look forward to hearing from you. Yours sincerely, Teija Kasteenpohja, MD Department of Health, Mental Health Unit, National Institute for Health and Welfare, Helsinki, Finland Postal address: P.O. Box 30, FIN Helsinki, Finland Tel.: fax.:

3 RESPONSE TO THE REVIEWERS: Title: Treatment adequacy of anxiety disorders among young adults in Finland Reviewer #1: The approach is sound, although some of the conclusions may be tempered in light of the data and the associate limitations. We have made a few changes into a manuscript according to this comment: Line 281: The sentence Unfortunately this pursuit sometimes seems to lead to inappropriate use of benzodiazepines. was changes to: Unfortunately this pursuit may sometimes lead to inappropriate use of benzodiazepines. Line : The sentence The results suggest that more attention should be paid to inappropriate prescription of BZDs to people with anxiety disorders in Finland. was changed to: The results suggest that more attention should be paid to prescription of BZDs to people with anxiety disorders in Finland. I struggle to consider a hospitalization of 4 days duration minimal treatment for an anxiety disorder. This threshold should be justified and it would be worth a post-hoc analysis with removal of those patients who qualified based on a brief hospitalization. Hospitalizations have not been used as an adequacy criterion in previous surveys, probably because detailed information on them has not been available. However, because we had accurate information about hospitalizations based on the national hospital discharge register and corresponding case records, we wanted to use it. We chose the four days time limit because we wanted to exclude for example short visits in the emergency department. Based on the information in the case records and the fact that evaluation period in Finland is four days, we decided that this time is enough to assess a diagnosis as well as plan and start a treatment. We emphasize that minimally adequate treatment only signifies that the minimum criterion for treatment adequacy is reached, it does not mean optimal treatment. This justification has now been added into a manuscript.

4 However, in our sample, there were 8 participants who had had a hospitalization for at least 4 days because of anxiety symptoms, and 7 of them had also received adequate treatment in outpatient care (lines ). If we take account only an adequate outpatient care, a percentage of minimally adequate treatment is 40.5% for the most recent treatment episode and 46.8% for the most intensive treatment episode of anxiety disorders. The presentation of adjusted odds ratios would be helpful. Regarding the issue of multicolinearity, many of the variables are ostensibly related and therefore adjustment in the models seems appropriate The presented odds ratios are adjusted. We have now clarified this in the footnotes of the tables 7 and 8. We could not include this information in the captions of the tables, because they may not exceed 15 words. Reviewer #2: This is a nicely written paper about an important topic but it needs a little more clarity in the text in the methods section in particular. Was the baseline data for MEAF actually drawn from the HEALTH 2000 study or did a sample of participants in HEALTH 2000 get selected for additional questionnaires for MEAF baseline? Yes, there was an additional questionnaire in MEAF based on which people were selected to the MEAF assessment. Health 2000 was a health survey based on a nationally representative twostage cluster sample which included 8028 persons aged 30 years (the adult sample) and 1894 persons aged years (the young adult sample). The original young adult assessment was carried out in 2001 and included questions related also to mental health, but a structured diagnostic interview was not conducted. That is why MEAF study, a follow-up study of the Health 2000 young adult study sample, was carried out. A questionnaire was mailed 2 4 years after the original study to all members of the young adult sample (N=1894), excluding those who had died (N=5) or refused further contacts (N=26) (Additional figure S1). The questionnaire consisted of several scales assessing mental health and substance use: K10 and the GHQ-12 for

5 general psychological distress, SCOFF for eating disorders, 22 questions on delusions and hallucinations for psychotic disorders from the CIDI interview, the MDQ for manic symptoms, and CAGE for alcohol abuse. All screen positive participants, and a random subsample of Health 2000 young adults regardless of their answers to the screening questionnaire, were asked to participate in the mental health interview. In addition, information from the Finnish National Hospital Discharge Register (NHDR) was used to identify all persons who had received hospital treatment due to any mental disorder [International Classification of Diseases (ICD)-10 section F, ICD-8 and ICD ], and they were asked to participate in the interview. A study flow of MEAF study is described more detailed in the references Suvisaari et al.: Mental disorders in young adulthood and Kasteenpohja et al.: Treatment received and treatment adequacy of depressive disorders among young adults in Finland. These already published reports provide detailed information on the screening procedure and attrition in different phases of the study. All screen positives, a random sample of screen negatives and all people who had received hospital treatment for any disorder were interviewed. How many of them were there and how were these three groups treated in the analysis? In the prevalence report of MEAF study (Jaana Suvisaari et al.: Mental disorders in young adulthood ) weights were used to correct the survey distributions to correspond to the population distributions. In this study we did not use weights, because the analysis was restricted to people with a lifetime anxiety disorders. We thought that adjusting for the sampling design (with 80 primary sampling units) would not be meaningful when the sample size of people with anxiety disorder excluding those with a single specific phobia is 79, and this was the reason for not using weights. I am not clear that the screen positives (for anxiety disorders) should have been merged with the people who had had hospital treatment for any disorder. might have been better to just add those who had been treated for an anxiety disorder.

6 We did not have a specific screen just for anxiety disorders, the screen was meant to capture any lifetime mental disorder. All persons of the Health 2000 young adult sample who had received hospital treatment due to any mental disorder were asked to participate in the interview, as well as all who in the questionnaire reported having had any treatment contact for any mental health related problem. The specific aspect of the register data was that we could access the medical records even if the person was unable to participate in the SCID interview. The study sample in the current study includes only those participants of MEAF study who had a lifetime diagnosis of anxiety disorder based on the SCID interview or case records. All case records of these participants were scrutinized, and all treatments analyzed in this study, in the outpatient clinics or hospitals, were related to anxiety disorders according to case records. This means that if for example the person had been treated for substance use disorder but a comorbid anxiety disorder was not taken into account in the treatment, we did not consider this as treatment for anxiety disorder. What was the refusal rate for each group? Non response is mentioned in the discussion but not in the results..it should at least be briefly summarised in this paper. Our previous report (Suvisaari et al Psychol Med Feb;39(2):287-99) has a detailed description and analysis of attrition at different stages of the study. In order to avoid double publication, such analysis was not reported here. However, the study flow and attrition at different stages is outlined in Additional figure S1. As previously reported (Suvisaari et al. 2009), people who did vs. did not participate in the MEAF interview did not differ in selfreported mental health in the MEAF questionnaire. People with a history of hospital treatment for any mental disorder participated less often, but this was compensated by their medical records which we received. Were any screen negatives false negatives, and if so what did you do with them? I cant find the screen negatives in the tables.

7 In a MEAF study a random sample of screen negatives were invited to an interview. Of them, 3 participants had a diagnosis of anxiety disorder based on the information from the interview. All these 3 participants also included in those 79 persons of our final sample and were investigated as others with a diagnosis of anxiety disorders. Naturally, all three belonged to the group which did not have any treatment contact, because having had any treatment contact was one of the screens. In the discussion, it would be helpful to clarify the first sentence eg " In our study of a nationally representative sample of 1894 young adults, 92 had an anxiety disorder identified either at research interview or by hospital admission and, of these 92, 70.9% had some kind of contact " The sentence has been clarified in the manuscript.