Author's response to reviews

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1 Author's response to reviews Title: Prevalence of psychological distress and mental disorders, and use of mental health services in the epidemiological catchment area of Montreal South-West Authors: Jean Caron Marie-Josée Fleury Michel Perreault Anne Crocker Jacques Tremblay Michel Tousignant Margaret Cargo Yan Kestens Mark Daniel Version: 3 Date: 22 August 2012 Author's response to reviews: see over

2 Paul Emmelkamp, Editor BMC Psychiatry I first want to thank you for giving us the opportunity to resubmit our manuscript. We have integrated most of the changes suggested by the reviewers and we also thank them for their comments and suggestions that have improved the quality of the article. The article has been revised by a professional editing service to correct the language. Tables and figure are now formatted according to the journal guidelines. Outlined below, you will find the changes we made in response to the reviewer s comments and suggestions. Reviewer 1 Minor Essential Revisions 1. First paragraph This is an odd way to start a paper. I suggest creating an abstract with this information. The abstract is now included. The absence of the abstract in the version submitted was due to a technical problem. 2. Methods, Instruments, paragraph 3 How is psychological stress deemed high, as indicated in Table 2? The cut-off point of 9 for determining high psychological distress is now presented in the Instrument s section under Psychological distress. The procedure for determining that cut-off is presented in another paper (Caron and Liu, 2011) and the reference is given. Here is the procedure used and presented in that paper: To obtain the optimal cut-off point, we conducted two approaches. In the first, logistic regression was used between continuous scores of psychological distress and mental disorders including depression, mania, panic disorder, social phobia, agoraphobia and substance dependence to compare the values of specificity and sensitivity for each possible cut-off point. The optimal cut-off point was 9 since it provides a sensitivity of 47.9% and a specificity of 91.7%; the area under the curve (AUC) was.836. The second approach, based on the criteria used in the Enquête Santé Québec, 34 uses the upper statistical quintile of the distribution of the K-10 scale among the total study population as the optimum cut-off point. This also

3 indicates a cut-off point of 9. As a result, the cut-off point for identifying high psychological distress was determined to be Table 1 Instead of unweighted and weighted percentages, it would be better to include unweighted n s and weighted percentages. That change has been made. 4. Results, prevalence of mental disorders Look over values in table, some of the values in text seem incorrect The reviewer was right; there were some incorrect values in the text and they have now been changed. How do you know that the prevalence of mental disorders was greater in YOUNGER women? The value given in the text is just for women in general. This was also an error in the text and it has been corrected. I would suggest calling alcohol abuse and drug dependence in this paragraph, Substance Dependence to be consistent with your table or alcohol and drug dependence The change has been made. The paragraph now reads as follows: The prevalence of mental disorders reached 16.7%; this percentage was slightly higher among younger people of years compared to those aged 55 and over (Table 2). Affective disorders were more prevalent in women but less prevalent in people older than 55 years old. The prevalence of anxiety disorders was 5.9% and women were overrepresented. Substance dependence was twice as high in men as in women while the prevalence stood at 6.2%. 5. Results, Table 3 Table 3 is inconsistent with the results section. It is presented with broad categories of any mood, any anxiety etc., whereas the results text discusses each disorder individually. Further, the paper does not explain how the values provided in the text for each individual disorder was obtained (neither in table format, not in the methods section) I suggest either: o modifying the table so that individual disorders appear OR o Addressing the broad category trends within the text This article aims to present a general description of our research program. In Table 2 and in the text, we present the prevalence for major categories of mental disorders

4 (there is therefore no inconsistency) as well as for specific disorders, we also present the comorbidity of mental disorders. We have chosen to present, in Table 3, sociodemographic correlates only for the major categories of mental disorders, for two reasons. The first is that if we were presenting the regressions for each of the mental disorders, that would increase substantially the length of the article and we think that the paper already contains a lot of material. In addition, articles are currently being prepared which will be concerned with each specific disorder and will present all correlates, including the socio-demographic variables. I also suggest a little more description in the methods, statistical analysis section to describe these analyses A more developed section of the statistics used now appears in the methods section. 6. Discussion, paragraph 10 Please comment as to why this is important, otherwise it is just results, rather than discussion. Explanation of the results is now presented. Discretionary Revisions 1. Methods, Sample, paragraph 3+4. This is all shown in table 1. Not sure if it s necessary to show in text. We extracted from Table 2 the principal points to facilitate reading. 2. Methods, Statistical Analysis Further explanation of the statistics, or show the results in tables. A more developed section on the statistics used now appears in the methods section. 3. Results, Table 3 Wondering if table 3 should be changed to individual disorders since this is the way it is presented in the results, rather than "any affective", "any anxiety"... Answered in point What is shown in table 2 does not need to be re-stated in results text, rather general trends should be stated We have removed from the text most of the percentages that appear in table 2.

5 Reviewer 2 Major compulsory revisions - There is no abstract included in the manuscript The abstract is now included. - Figure 1 is missing. The figure 1 is now included. - The statistical analyses in the methods section are poorly described. E.g., in Tab. 2 the Cochran-Armitage trend test was employed. It is not clearly described why Chi-Square Tests were used to compare for group differences of continuous measures such as the K-10 scale. Has it been transformed into dichotomized variables? Furthermore, the logistic regression analysis has to be specified concerning the procedure chosen. Has the p-value been corrected for multiple testing? A more developed section on the statistics used now appears in the methods section. - The last paragraph of conclusions ( This program is innovative ) is not a conclusion that can be drawn from the presented data and discussion. It refers to measures and data that are not part of this manuscript. The conclusions should therefore be revised substantially. A new conclusion drawn from the presented data is now presented. What appeared previously in the conclusion has been grouped under a new section called: Limits and strengths of the study, and future direction of the program. Minor essential revisions - The first paragraph should be headed by Background. This change has been made. - The introduction describes mainly the objectives and the theoretical model of the wider research program. The research questions posed by the authors concerning the present manuscript should be framed more concretely at the end of the paragraph. We have stated the objectives more specifically. We also present the results of the prevalence of psychological distress and mental disorders and the use of mental health services and their correlates for the first wave of data collection in this longitudinal study. More specifically, the influence of age and sex on the prevalences will be examined as well as the comorbidity of mental disorders by sex. Finally, vulnerable groups and socio-demographic risk factors of psychological distress and of mental disorders are presented.

6 The data are sound and well described. There are a few minor revisions necessary: - Please consider revision of the sentence on p.11 last line:..women were likely have depression than men.. ; and p. 13 first line: followed by were single, - p. 15, last paragraph: Table 3 presents this comorbidity by gender and disorder : this is obviously not the case as table 3 presents logistic regression analyses and does not provide information on comorbidity. This has been corrected. - p. 17 2nd paragraph: Immigrants showed lower risk for drug dependence and affective disorders the latter is not supported by the results displayed in table 3 as OR for affective disorders is not significant. The reviewer was correct; the new paragraph is as following: Immigrants showed a lower risk (OR= 0.31) for drug dependence than nonimmigrants - The discussion is well balanced and adequately supported by the data. The limitations should be positioned under the subheading discussion instead of conclusions. This has been done. Discretionary revisions Setting and Sample are appropriately described. It does not seem to be necessary to describe all the instruments used in the research program that will not be relevant to the results of the present manuscript. As one of the objectives of the paper is to describe the general method of the program, we believe that the presentation of all the instruments may be of interest to readers so that they can see how the variables in the theoretical model, in figure 1, are measured.