Review: Prevalence of depression, anxiety, and PTSD symptoms among patients of opioid agonist treatment programmes in Ukraine during wartime {under peer review}

 

Reviewer: Mariia Mezhenska

 

Completed: 06-10-2025 07:13

 

Recommendation: Accept Submission

 

 

	Yes	No	N/A
Is the research question clearly defined?	+
Are the methods appropriate and sufficiently detailed?	+
Is the data analysis robust and replicable?	+
Are the conclusions supported by the results?	+
Is the manuscript well organised and clearly written?	+
Are tables, figures, and supplementary material informative and necessary?	+
Is the abstract an accurate summary of the study?	+
Does the manuscript contribute meaningfully to the field?	+
Is it relevant to the field of mental health or related disciplines that are connected to the scope of the Journal?	+
Are ethical approvals and participant consents adequately described?	+
Have competing interests, funding, and data availability been transparently declared?	+

 

Comments for the authors:

 

The article, “Prevalence of depression, anxiety, and PTSD symptoms among patients of opioid agonist treatment programmes in Ukraine during wartime,” examines point prevalence and co-occurrence of depression, generalized anxiety, PTSD symptoms, and suicidal ideation among OAT patients in 2023 (war year 2), and compares these outcomes with a pre-war clinic sample from late 2021 - early 2022. The topic is timely and important, the paper is generally clear, and the clinical relevance is high.

I recommend acceptance with minor revisions that will materially improve transparency and interpretability without altering the main conclusions.

The central inference hinges on comparing two independent clinic cohorts. Comparability of the two cohorts is currently under-reported and needs to be shown. Because the pre-war sample (Kyiv/Lviv/Sumy) differs in composition from the wartime sample (Vinnytsia/Lviv/Sumy), readers need to see whether cross-cohort differences reflect true changes or simply different case-mix. The article would benefit from adding two concise descriptive tables, one for each cohort, reporting, at a minimum, gender, age, city, and OAT medication (methadone/buprenorphine/buvidal), with n/N shown for each stratum. Alongside those tables, acknowledge explicitly that Kyiv was replaced by Vinnytsia in the wartime wave. If possible, include a brief sensitivity check restricting pre/post comparisons to the overlapping sites (Lviv and Sumy); if re-analysis is not feasible, a clear caveat in Results and Limitations about the site swap and possible influence of confounders that was not tested is sufficient.

The pre/post analyses themselves are currently unadjusted (Mann–Whitney U for severity; χ² for prevalence), and therefore they compare the two time periods without controlling for things that also differed between periods (site mix: Kyiv vs Vinnytsia; season/month of data collection (pre-war (Oct–Jan) vs war-year-2 (Apr–Oct)) invites seasonal effects on mood/anxiety; gender proportions; medication mix). If those factors relate to the outcomes, they can confound the pre-/post-contrast. Reasonable confounders should be mentioned in the Discussion and the Limitations sections. Reporting effect sizes with 95% CIs throughout the article and interpreting the results as associations rather than causal effects is necessary. If the authors can add one lightweight robustness model (e.g., a site-adjusted logistic regression for the primary prevalence outcomes (pre vs during + site as a covariate), that would further strengthen confidence without expanding the paper.

In the Participants section (in the Methods section, not the Results), reporting sample sizes for each cohort and providing a brief description of each sample (sites, gender distribution, age, and OAT medication mix) is highly desirable. The manuscript should also explicitly state that informed consent was obtained. Moreover, because screening was interviewer-administered by clinic staff, noting in the Limitations the risks of social desirability and interviewer bias, especially potential underreporting of suicidal ideation, and briefly describing privacy safeguards (private setting, standardized script, and whether a self-administration option was offered) is highly recommended. Finally, nonresponse on trauma/PTSD is substantial and likely informative (376 refused LEC-5; only 608 completed LEC-5, and 549 trauma-exposed completed PCL-5), so PTSD prevalence is plausibly underestimated (people with the highest trauma may refuse).

Furthermore, the manuscript would benefit from a brief Methods subsection describing each measurement scale (PHQ-9, GAD-7, PCL-5 with LEC-5 anchoring, and PHQ-9 item 9 for suicidal ideation; number of items used in the current study) and reporting summary statistics for each cohort; as well as a succinct Data Analytics section explaining the rationale for each analysis choice.

Medication group contrasts (higher suicidal ideation/PTSD among buprenorphine vs methadone recipients) are valuable but potentially influenced by confounders. Framing these as exploratory and presenting minimal adjusted comparisons (medication + age + gender + site) with adjusted odds ratios and CIs, ideally in a compact supplement, would temper inference.

Clinical relevance warrants explicit comment where statistically significant differences are small. For example, the PHQ-9 mean increase from 7.42 to 7.90 is modest; reporting the standardized mean difference and noting that the absolute change appears below typical minimal clinically important difference thresholds would help avoid over-interpretation of p-values.

Several small inconsistencies are present, which I believe are typos, but should be fixed. Sex counts are reversed in text (it says “95 males, 889 females”; tables indicate 95 females, 889 males) and the methadone totals (764 in tables vs 746 elsewhere).

Thank you for the opportunity to review this important work. The study addresses a pressing public health question under exceptionally challenging circumstances, and the effort by the authors and clinic teams is commendable. The suggestions above are largely clarifications that enhance transparency rather than changes to the study’s core message. With these interpretive notes in mind, the manuscript stands as a valuable contribution to understanding mental health among OAT patients during wartime, and it will be of clear interest to clinicians, program leaders, and policymakers.