Factors Related to the Willingness of People with Mental Health Illnesses Living in Group Homes to Disclose Their Illness to Supporters during Disaster Evacuation: A Cross-Sectional Study

Round 1

Reviewer 1 Report

For people who are vulnerable to disasters, the damage is especially severe. Living in an evacuation shelter also has a significant impact on mental health. This manuscript aimed to to identify predictors of the willingness of PMHI living in group homes in Japan to disclose their illness to their supporters when evacuated because of a disaster. It is not easy for PMHI to ask supporters for help in the event of a disaster or emergency because the stigma surrounding mental illness is a barrier to PMHI disclosing their illness and seeking professional help. Therefore, this manuscript has novelity and meaning for disaster preparedness of PMHI who vulnerable to disasters. However, there are some issues to be addressed for considering the publication. My comments were as belows:

#1. keywords

Please consider to use mesh terms. Change evacuation shelters to emergency shelter. Is 'people with mental health illnesses' and 'disclosing my illness' appropriate as keyword? 

#2. Introduction

This section is too long and overly detailed. I recommend you summarize this section to about half. As many as total 48 references were cited in this section. You should summarize this section using essential recent references. Delete or move unnessary sentences. Moreover, the rationale of this study is insufficient. Especially, you stressed the stigma surrounding PMHI and  a barrier to PMHI disclosing their illness and seeking professional help. 

Materials and Methods

#3. The participants

"The participants were PMHI who use a group home for mentally ill people in Ishikawa Prefecture, Japan"

Provide clear and specific definition regarding PMHI as inclusion criteria of your study.

#4.  questionnaire

Provide the detailed process of development of this questionnaire. 

#5. 

"This 154 survey investigated the actual living conditions of mentally disabled people in 155 Minamisoma City who were victims of the 2011 Great East Japan Earthquake and pos-156 sessed mental disability certificates"

Provide relevant reference. 

Discussion

#6. 

First, you need to provide the main results in the first paragraph (what is take home message of this study?).

#7. Limitation and future study suggestion. 

Provide specific suggestions for future study and policy change to address many limitaions fo this study. Use relevant refernces. 

#8. Conclusion

Based on your main results, you need to summarize and re-write this section. What is main results and implications of this study?

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

I believe that the surveyed area for this manuscript was hit by the Noto Peninsula earthquake of 2024. I pray for the earliest possible recovery and reconstruction of the affected areas.

In light of the above, this manuscript should be published as soon as possible.　If possible, I would like a map of Japan showing the location of Ishikawa Prefecture and a map showing the location of the group homes surveyed in Ishikawa Prefecture.

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

Factors related to the intention of people with mental health illness living in group homes to disclose their illness to sup-porters during disaster evacuation: A cross sectional study

The authors did a nice job in the literature review citing evidence for the risk for psychiatric patients who experience secondary stressors, e.g., related to natural disasters and other secondary stressors. When displaced, the authors showed literature supporting the idea that there could be a worsening of symptoms related to the trauma surrounding the natural disaster. They also did a nice job talking about the types of symptoms associated with living in a shelter, making the point that significant psychiatric, medical, and behavioral presentations may change as well as the development of new psychiatric symptoms because of the increased stress.

Line 126: Starting here, the authors make a sweeping assumption without having any literature backup for it – the idea that disclosing mental health illness will help patients survive in a disaster situation, almost stating it as if it here a fact. Where is the literature to back this up? They talk about “requesting appropriate considerations.” What kind of considerations are you referring to? If someone is being evacuated and it is a matter of life and death, what kind of things could make it better for a person with a mental health condition? And is this different from disclosure once the person is in a shelter? So, this section is problematic. The authors have not provided evidence that things would be better for those who disclose. Literature is needed to provide evidence for this to even justify the study. Instead, again, the authors seem to be making this assumption without any kind of proof. And what does this look like? Is it disclosure alone? That seems too simplistic.  What would the rescuers need to be doing to provide support? This was never flushed out in the study, e.g., no literature to back it up and no discussion of how that helped survive their new accommodations. 

Line 329: What kind of appropriate consideration are you referring to? What could supporters do to help? 

Line 332: You make a good point about stigma, and how that might be a barrier to self-disclosure, yet you didn’t measure that.

It seems to me that there were missed opportunities with this study.  First, it would have been a much better study if it were longitudinal instead of cross-sectional. Then you could assess things like: 1. If a patient were to self-disclose, were they more likely to stay in the shelter? Were they more likely to experience less negative symptoms while in the shelter? 2.  What could rescuers/supporters do that makes it better for the patients?

The best part of this study is the initial literature review showing evidence that natural disaster stressors negatively affect people who already have a history of mental illness.

Title: Sup-Porters = supporters

Title: Sup-Porters = supporters

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Although authors did efforts to response comments, there are still some issues to be addressed sufficiently.

#1. keywords

Mental illnesses is not mesh term. Please consider to use mesh terms. You can consider many entry term.

emergency shelters => emergency shelter

#2. Introduction

Paragraph 2 and 3 are still overly detailed. I recommend you summarize these paragraph using essential recent references.

#3. Limitation and future study suggestion.

Use relevant references not just your opinion in this paragraph.

#4. Conclusion

Conclusion is too long. Conclusion is summary of your main results. Conclusion should not be divided. You do not use any citations in here. ("and increase community support for these populations [62,63].")

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

Factors related to the intention of people wit mental health illnesses living in group homes to disclose their illness to supporters during disaster evacuation: A cross-sectional study

After reading the first version, I found myself asking the question, why would it be important to self-disclose about mental health issues during an evacuation. While I had my thoughts about why that might be important, nothing was clearly outlined in the original piece. Now things are better explained.  The authors contend that those who are willing to self-disclose are more likely to think about disaster preparedness, imagine themselves evacuating, and ultimately save their life. They also now have the link in the discussion that those who evacuate and go into a shelter... if they self-disclose, they are more likely to receive accommodations.  At least now there is a reason for wondering about self-disclosure during evacuation which was missing before. But I still have some questions that are not answered in this manuscript. First, did those who didn't disclose NOT go to shelters? Not do as well in the shelter? They have some literature review that talks about people with mental health issues who experience the stress of a natural disaster and evacuation showing increased symptomatology.  That completely makes sense, but that wasn't measured. They looked at who would self-disclose and who would not, which is helpful to know.  However, the implications of that wasn't measured. And that is a lost opportunity.

I was happy to see in the discussion an answer to my original question.... what do patients get if they self-disclose. The answer is increased accommodations. Wonderful. But did they? And what might those accommodations look like? For these reasons, I am not sure that the conclusions are that informative. However, the new information about what circumstances need to be there for someone to self-disclose could be important.  It's too bad that more of the story wasn't answered.

Author Response

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Author Response File: Author Response.pdf