Dimensions of Religion Associated with Suicide Attempt and Ideation: A 15-Month Prospective Study in a Dutch Psychiatric Population

Round 1

Reviewer 1 Report

This is an interesting study with some rather unexpected findings about variability of different R/S aspects over time, e.g., that affective disorders can bring changes in the affective aspects of God representations.

I wonder why responce rate (38%) at T1 was so low, could you add some short considerations?

It is not clear enough how suicidality was assessed. Was it only suicidal ideation? You mention other risk factors for suicidal behavior, but were they included into evaluation of suicidality?

The sample was mainly protestant Christians, but were there other Christians? (Classical sociological theories of suicidality claim different suicidal risk of different denominations)

 

 

Author Response

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Thank you very much for your review.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The article “Dimensions of Religion Associated With Suicide Attempt and 3 Ideation: A 15-Month Prospective Study in a Dutch psychiatric 4 population” is the result of a longitudinal study in which the authors explored the dynamic interlink between different dimensions of religiosity and the suicidal intentions and ideation in a group of patients diagnosed with major depression. Despite the small dimension of the investigated group, the results of the statistical analyses showed that the affective aspects of religiosity display a positive change from t0 to t1, and that “supportive religiosity outcomes” predicts a lower level of suicidality. In addition, changes in suicidality proved to be a consequence of a decrease in the depressive symptoms. The present study stresses the importance of including the religiosity dimension in the psychiatric assessment of depression and suicidality. Also, the authors plead for the inclusion of religious activities in the individual treatment plan. Thus, the interveners could exploit the possible protective role of spiritual activities in the healing process.    

The article has a coherent and logical structure. The informational content is based on 42 bibliographic sources, relevant to the investigated topic. The authors used the self-citations moderately.

Each section was constructed in a clearly and concisely manner. The research methodology used in the study fitted the objectives in a proper way and was appropriate for the hypothesis testing process. The sampling procedure was sufficiently explained. The main ethics of research issues were mentioned in the manuscript. The attention the authors dedicated to limitations of the study is worth mentioning.

To improve the quality of the article, I recommend the authors the following little adjustments:

In the sub-section 2.1. Procedure:

- I would recommend indicating the period of the first assessment (the time span for t0). Although in the manuscript it is mentioned the duration of the evaluation (15 months) and the period of the second assessment (the time span for t1), it would be clearer for the reader to find in the text the period of the first assessment.

- Taking into consideration the sensitivity of the investigated topic and the vulnerability at which the patients with a history of suicidality and major depression are exposed to, I believe that using the “1964 Declaration of Helsinki” as ethical framework for the present research is caducous, even if it was considered sufficient by the ethical committee. I would suggest at least to add a mention that this declaration was the ethical benchmark of the study with the amendments made on it since its release.

- For the same reasons of sensitivity and vulnerability related to the studied topic and category of respondents, I would suggest to include in this sub-section a short description of the team responsible with data collection (their backgrounds and how their were trained in order to get complete and honest answers). The authors mentioned about “trained psychologists” at the sub-section dedicated to the instruments of data collection (lines 104-105), but it is not clear that this study involved only psychologists in the process of data collection.

In the sub-section 2.2. Instruments:

- At line 116, please delete the “dot” after the word Suicidality. It is the title of the sub-section 2.2.2.

- Please use the quotation marks uniformly! As you used predominantly the version with double comma, as in the line 128, change the variant used in the line 118 and close the quotation mark at the end of the phrase, in the line 120, as follows: “During the past four weeks, have you reached a point where you seriously considered taking your life or perhaps made plans how you would go about doing it?”

- For the first mentioned scale presented in this sub-section -  the five-item Paykel Suicide Items (PSI), the authors indicated the range of it - 5–24 (in the lines 117-118). I recommend to the authors to keep indicating the range for the other scales described and used in the study (for example, for the scales mentioned between the lines 124-135)!

- I would suggest the operationalization of the level of education in a more precise way, possibly as: low (8-11 years), medium (12-17 years), or high (18+ years).

In the section 3. Results:

- As a general suggestion when reporting the results of the statistical analysis, I would recommend the authors to use the past tense of the verbs.

- Below the Tables 1, 2 and 3, and below the two figures, please insert a note specifying whether the content is calculated or generated by the authors. If not, please indicate the source of data.

- In the Table 1, please verify if the mentioned value for the low level of education (<9y) has the same cut off point as defined in the sub-section dedicated to instruments (line 158).

- At Table 2, in the 3^rd and 4^th columns of results (Pearson’s product-moment correlation and Paired samples t-test value, with p-values), I consider redundant to indicate the significant values of p both in a(n exact) numeric format (for example, < .001 or .015) and in a symbolic manner (** or *). I suggest the authors to choose a single modality to indicate the level of significance (p-value), that they consider more relevant and suggestive, or to follow the rules of the journal.

- If the results of testing the second hypothesis (lines 280-290) are not comprised in a table or in a figure, the authors should indicate this in the text!

Taking all the above into consideration, I recommend publishing the article with minor revisions, because it is of high interest not only for the professionals working in the mental health field, but also for the public at the large.

Submission Date

06 March 2023

Author Response

All point are processed, adaptations made.

Please see attachment.

Thank you very much for your detailed and helpful review.

Author Response File: Author Response.pdf

Reviewer 3 Report

One of a few follow up studies on R/S and suicidality to investistigate the protective or worsening role of R/S regarding suicidal ideation. One of the qualities is the multidimensional assessment of R/S. The statistics are impressive.

The observational prospective study consists of a baseline measurement and one follow-up assessement after 15 months.

There are some major critical aspects that should be modified for revision:

1. The term "Associated With Suicide Attempt" in the title of the paper is misleading. The are no results concerning Suicide Attemps in the study, only suicidal ideation is measured by Paykel Suicide Items. Please remove the term "Suicide Attempt" from the title.

2. The information on the sample is scarce. Please add information regarding comorbidties, and treatment information during the period of 15 months until follow up (did the participants recive psychotherapeutic treatment or medication). What is the impact of treatment on reduction of suicidal ideation? Is it really the "natural cource of a depressive episode" (342) or is the result of a treatment impact?

3. The response rate of 38% is relative small. The drop out rate or "loss to follow up" is 61%. What are the reasons for this amount? Please discuss and problematize the drop out rate.

4. The comparison between the T0 sample and the T1 subsample is not really satisfying. Please compare the T1 subsample to the "loss to follow up" subsample (96 persons) and compute a chi-square-analysis for the demographic and psychopathological characteristics. If there are significant differences, please discuss internal validity. Why is the religious salience only assessed at T0.

5. Becauce of the high rate of dutch protestant/reformed participants treated in the Eleos Institute, please discuss the predominant theology  of this religious group towards suicide, god representation and moral objections to  suicide.

6. Please remove the last two sentences from the manuscript (485-487) "This section may be divided by subheadings. It should provide a concise and precise description of the experimental results, their interpretation, as well as the experimental conclusions that can be drawn."

7. I understand the results of the stuy as follows: It´s more the course of depressive symptomatology  than  aspects of R/S that influences suicidal ideation. If this conclusion is right, please make it more clear.

Author Response

All point are processed, adaptations made.

Please see attachment.

Thank you very much for your valuable review.

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Thank You for your revision. I reccomend to accept it in the present form.