Title: Prevalence of anxiety and depression among Lebanese women using oral contraceptives:
A cross-sectional study
Version: 2 Date: 08 Nov 2023
Reviewer:  Zaher Nazzal
Reviewer's report:
Thank you for letting me to review this manuscript. The study addresses an important
topic, which is the prevalence of anxiety and depression among Lebanese women using oral
contraceptive pills. I suggested some comments to enhance the current paper:
Introduction:
The introduction requires improvement and reinforcement. The authors rely heavily on outdated
references and frequently repeat the same concept, such as the uncertainty of the relationship
between OCs and depression and anxiety.
- The authors mention that depression as a side effect of OCs was noted in the 1960s, which led
to a decrease in their use, and added that the current understanding of the connection between
OCs and depression remains uncertain. This statement relies on outdated evidence (very old
references). We should incorporate more recent research findings on the topic since there is a
wealth of new studies available, rather than depending solely on older sources.
- Reference number 11 is considerably outdated, and we cannot establish the foundation for this
study solely on such an outdated source. This section requires an update to clearly articulate the
driving factors for conducting this study, its significance, and the rationale behind its necessity.
- It would be beneficial if authors provided an overview of the existing literature concerning the
issue within the neighboring Middle Eastern area.
Methods:
In research, exclusions do not refer to the opposite of inclusions. Exclusion criteria are defined
as features of the potential study participants who meet the inclusion criteria but present with
additional characteristics that could interfere with the success of the study or increase their risk
for an unfavorable outcome. Please rephrase your eligibility criteria accordingly.
It wasn’t clear whether the pilot study was carried out through online or in-person interactions.
Do you believe that a sample size of 5 is sufficient for a pilot study?
Results:
The sentence in the results section, "….. and it was higher among participants taking POP 89.2%
as compared to COC users 10.8%," appears unclear and does not align with the information
presented in figure 2. Please revise it to match the figure consistently.
All the figures are of low quality and need edits:
-  Improve the clarity and quality of all figures
- Remove the title from inside of each figure
- Make the key to each figure clear
- Figures 1 and 3 can be combined with figures 2 and 4; they are not required separately.
The significance level was set at <0.05, so why to add below some tables and figures “Significant
at p-value <0.001”. I didn’t get this point and why it was added?
The significance level was set at <0.05, so why include the statement "Significant at p-value
<0.001" below some tables and figures? I'm unsure of the purpose behind adding this statement.
It is confusing and I believe it should be deleted.
I suggest employing row percentages rather than column percentages to get a better
understanding of the frequency and percentages reported in tables 2 and 3.
Discussion:
The discussion primarily focused on summarizing the results related to oral contraceptives and
their connection to depression and anxiety. However, it lacks a thorough interpretation and often
overlooks the implications of these findings. Additionally, the discussion fails to provide an
analysis of other significant findings from the multivariate analysis, such as income per month,
marital status, and smoking.
The results on the relationship with smoking is somewhat confusing, as it appears to be
considered both a protective factor for anxiety and a risk factor for depression, and this requires
a clearer explanation and interpretation by authors.
Utilizing a self-administered questionnaire might restrict the study's participation to women
possessing particular socioeconomic attributes, primarily those with higher educational
backgrounds. I suggest acknowledging this point in the limitation section.
References:
The reference list contains several very old reference, that can’t be accepted! Sometimes we
use old reference, but their use should be justified. The authors should justify the use of the old
references or they should update all their literature review.
The authors failed to adhere to the proper formatting guidelines of using a standard style for
references, as they were inappropriately structured. It is advisable for them to adhere to the
journal's guidelines regarding the correct citation style.
General comments:
The authors did not adhere to the abbreviation writing guidelines, as they should have initially
spelled out the full form the first time they were used, followed by the abbreviation. In many
instances, they repeated the full form unnecessarily.
The manuscript requires English and professional writing editing, with a specific focus on the
methods and results section.