Reviewer ’s rep ort 
 
Title: Burden, Screening, and Treatment of Depressive and Anxious Symptoms among Women 
Referred To Cardiac Rehabilitation: A Prospective Study  
 
Version: 1 Date: 22 Aug 2016  
 
Reviewer: Joel W. Hughes  
 
Reviewer's report:  
 
This interesting study once again documents that mental health treatment of cardiac patient s, this 
time women, is chaotic, inadequate, and potentially ineffective.  
However, readers will want to consider some limitations of the study. The loss of participants to 
the follow up assessment is a considerable concern which the authors described as " declined to 
return." I don't think they are all an active decision to decline, as some loss to follow -up is 
probably less inentional than declining to participate. Still, as they demonstrate, those lost to 
follow -up were systematically different from those  retained. This causes interpretation problems. 
Also, it was unfortunately not possible to verify depression screening from medical chart 
information. Although patients reported low rates of having been screened for depression, I 
suspect that some of them were screened but no longer remember. When we contact participants 
for follow -up assessments in cardiovascular research, some forgot the hours -long assessment 
protocol that they completed solely for the purposes of research, and ask who we are and why we 
are calling! This line of research would be greatly strenghened by cross referencing the chart 
(e.g., PHQ form in their record) against their recall of having been screened or not.  
It is distressing that so few people were referred for any treatment other  than pharmacological 
treatments. Of course, the "dodo bird" effect applies to mild cases of depression (all treatments 
are equal and similar to no treatment), and maybe treatment providers know this --the more 
severe cases (e.g., recurrent major depression , severe major depression) are most likely to 
respond to treatment of any kind. Furthermore, all patients were referred to cardiac rehabilitaion, 
which is a very reasonable approach to treating depression, especialy at the milder end of the 
continuum. Exer cise is great medicine and is reliably associated with improved mood in 
depressed patients.  
Are the methods appropriate and well de scribed?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately s upported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, plea se specify what aspects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
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