Title: Depression, anxiety, and stress in polycystic ovary syndrome: understanding the impact
of adult separation anxiety and uncertainty intolerance
Version: 4 Date: 28 Jun 2025
Reviewer's report:
I would like to thank the research team again for carefully going through the reviewer comments
to improve the quality of the article. As it stands, I think this paper is ready for publication,
with some minor corrections. I hope the other reviewer was able to comprehensively cover the
statistical components, but I have added some comments here, just in case, because I think there
are parts missing.
Thank you so much for your effort and the paper reads much more clearly now.
1. Could you add your findings regarding ASA in your abstract (either results/conclusion; as
this is the primary objective of your paper)?
2. “It occurs brought on” to “It is brought on”
3. “can aggravate psychological weaknesses”, can be phrased in a more ethical way, rather than
making patients out to be having “weakness”, can say “can aggravate psychological conditions,
including”
4. Sometimes, there needs to be transitional words and phrases so the flow of the authors’
argument is clear: “Adult separation anxiety is an anxiety disorder reported in the DSM-5 as
occurring in adulthood.” Can change to “Adult separation anxiety is one such anxiety disorder
reported in the DSM-5 as occurring in adulthood.”
5. This paragraph can be reordered a bit for clarity: “Anxiety is a common mental health
condition…”
6. I think the flow the authors are trying to have in the introduction/discussion is: anxiety - IOU
is a transdiagnostic factor - as such, (we hypothesize) other IOU related conditions, such as
ASA, should also be prevalent in anxiety afflicted populations - PCOS also comes with anxiety
- thus, (we hypothesize), also ASA. I think this is the order? This ordering could be clearer in
the discussion section.
7. “included questions about the participants’ gender, age,”, you can remove the apostrophe and
just say, “about participant gender, age”
8. “The first 7 questions consist of the 'prospective anxiety' subscale related to cognitions about
uncertain future events; the last 5 questions consist of the 'inhibitory anxiety' subscale related to
anxiety symptoms and behavioral symptoms related to uncertainty.” The authors do not really
discuss these subscales, I would ask the authors to maybe add a line about that!
9. Also, I would encourage the authors to add a bit of recent clinical literature, as it’s 2025 now,
such as major papers from 2023-2025.
Nasiri-Amiri, F., Faramarzi, M., Omidvar, S., & Alizadeh-Navaei, R. (2023). Depression and
anxiety in adolescents and young women with polycystic ovary syndrome: a systematic review
and meta-analysis. International Journal of Adolescent Medicine and Health, 35(3), 233-242.
https://doi.org/10.1515/ijamh-2022-0065
Cevik Dogan, M., & Yoldemir, T. (2024). The association between female sexual function and
metabolic features of the polycystic ovary syndrome in Turkish women of reproductive age.
Gynecological Endocrinology, 40(1), 2362249.
And bits about lived experiences (which do talk about uncertainty in PCOS, which can support
the paper’s findings), such as:
Wright, P. J., Dawson, R. M., & Corbett, C. F. (2024). Exploring the Experiential Journey
of Women with PCOS Across the Lifespan: A Qualitative Inquiry. International Journal of
Women's Health, 1159-1171.
10. This first sentence is a bit odd, so a “more profound comprehension” or understandings
necessitates a "more holistic approach to treatment”? Why use the term “profound”? The link
between these two components is unclear; for example, perhaps it could also lead to more
“specific” approach? This runs the risk of being a vague statement.
A more profound comprehension of these pathways necessitates a more holistic approach to
therapeutic programs for the mental health of those diagnosed with PCOS.
11. “Female” is a term more used for biological purposes, “women or girl” is more commonly
used for gender. I would ask the authors to use the terms women and/or girls, according to their
preference.
In 2015, a large-scale study investigating separation anxiety disorder among countries in the
World Mental Health Survey reported that, when controlling for age and country, female
gender and low educational level could be considered predictors of adult separation anxiety
symptoms[42].
11. “Another limitation of our study is that the symptoms of adult separation anxiety and other
mental symptoms were evaluated with self-report scales and not compared with matched healthy
controls”, could you clarify the implications of this? What is a “healthy” control in this instance?
Methodology
A statement about the location of research.
A statement about the approach to recruiting participants, how the data collection tools were
adminstered, e.g., by who to who?
Was there any missingness of data?
Reflexivity, I’m not sure if the authors will find this useful, but
"Does the researcher recognise their own positionality in the research process? For
example, taking into account their own biases or position of weakness or power in relation to
the study participants.”
I would encourage the authors to take a look at this reporting checklist from 2024:
Symonds, J. E. & Tang, X. (2024). Quality appraisal checklist for quantitative, qualitative, and
mixed methods studies. PsyArXiv.
Thank you very much!