Reviewer ’s report  
 
Title: Burden, Screening, and Treatment of Depressive and Anxious Symptoms among Women  
Referred To Cardiac Rehabilitation: A Prospective Study  
 
Version: 1 Date: 16 Dec 2015  
 
Reviewer: Angele McGrady  
 
Reviewer's report:  
 
This is a study of mood and anxiety symptoms in women referred to cardiac rehabilitation: how 
women are screened, treated for mood and  anxiety symptoms and their outcome. This is an 
important area of research since CVD is a major source of morbidity and mortality in women. 
The conclusions are that there is insufficient screening, inadequate treatment for those patients 
with symptoms and when treated, outcome is marginally successful.  
There are some conceptual problems with the manuscript. The emphasis on the participants 
memory of being screening is ill placed. Patients entering cardiac rehab are faced with multiple 
situations in which " bad news" is given. They have had a cardiac event - it was serious - they 
need months of cardiac rehab - they are scoring high on mood and anxiety inventories - they 
need medication.... What is important is whether or not they were screened and if positive , what 
treatment was recommended. Follow up on recommended psychiatric/psychological treatment is 
notoriously bad; the PCP may initiate treatment, but not follow up. If there is a psychologist on 
site in the cardiac rehab facility, follow through is much b etter. The authors should describe the 
set up of the 3 models of cardiac rehab and list the staff. How much staff contact did the home 
based CR participants have? If screening for depression and anxiety is required prior to entrance 
into cardiac rehab and the screening rates are low are you implying that the recommended 
protocols are not being followed? Since your results contradict most other reports, further 
analysis, perhaps by type of rehab, by age, by diagnosis is warranted to explain these findings. 
With regard to the excessive burden of psychosocial distress in this group, there is no 
comparison with other groups - male, female, SES, etc and the rates of depression and anxiety 
are not significantly higher in your study than in others. Disease burden i s a broader term than 
distress and the authors seem to equate them. You showed that a high percent of women with 
CHD are experiencing distress, but you did not gather data on "burden" of disease.  
 
Additional comments: why is only the HADS mentioned in the abstract and not the other 
inventories?  
Mood and anxiety symptoms have different effects on adherence and this is not discussed  
The high percent of women with positive screens is not a new finding.  
The authors do describe what types of medications were prescribed for those who screened 
positive, but not the type of psychotherapy.  
The timing of asking patients to remember being screened and the actual time of screening is 
unclear to me.  
page 12 1st p aragraph; it is known that drop outs have higher baseline depression and anxiety 
scores; you have those values; provide them for the reader.  
Page 13 paragraph that begins.. At follow up.....states a significant decrease in PHQ -2 scores at 
follow up; but th e conclusions state no effect of treatment.  
End of that paragraph; CR programs are sessions of exercise (US - 36 sessions recommended); 
why no changes in exercise behavior?  
page 15 -16 - state whether the HADS scores are in the clinical range  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, ple ase specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscrip t or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written Eng lish 
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares  in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you recei ved reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
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