Prevalence of depression and associated factors among adult cancer patients receiving chemotherapy during the era of COVID-19 in Ethiopia. Hospital-based cross-sectional study.

BACKGROUND: Depression is a major public health problem among cancer patients undergoing chemotherapy. It compromises patient outcomes, resulting in higher rates of mortality. Currently, there are little data on the prevalence of depression in Sub-Sharan countries. Therefore, the current study was done to assess the prevalence of depression among adult cancer patients and its associated factors in Ethiopia.
METHOD: An institutional based cross-sectional study was conducted among 420 adult cancer patients from 1st March to April 30, 2021. Systematic random sampling technique was used to recruit participants. Depression was assessed using the Patient Health Questionnaire-9. The collected data were coded and entered into Epi-data version 4.2 and exported to SPSS version 25 for analysis. Bivariate binary logistic regression was performed to select factors that will be included in multivariate analysis, and variables with a p-value < 0.05 were included in multivariate analysis. In multivariate analysis, odds ratios and their 95% confidence intervals were computed and variables with p-value < 0.05 were considered to declare a significant association.
RESULTS: In this study, the prevalence of depression was 33.1% (95% CI = 0.2858, 0.3761). Minimal symptoms of depression, minor depression, moderate depression, moderate severe depression, and severe depression were found to be 272 (64.8%), 9 (2.1%), 104 (24.8%), 28 (6.7%), and 7 (1.7%), respectively. Those cancer patients who had unemployed status, sacked from jobs, and had stage IV cancer were most likely to develop depression, whereas patients who completed primary education, colon, prostate and cervical cancer were less likely to have depression.
CONCLUSION: Depression is found to be a major public health concern for adult cancer patients in Ethiopia. To reduce the occurrence of depression among cancer patients, special attention is needed.

Background

Worldwide, new cancer cases, and cancer deaths were estimated to be 19.3 million and 10 million, respectively, in 2020. The global cancer burden is expected to be 28.4 million cases in 2040, a 47% rise from 2020 [1]. Well-recognized risk factors for cancer are tobacco use, poor physical activity, poor nutrition [2], obesity [3] and excessive alcohol consumption [4, 5]. The treatment of cancer includes three main modalities namely surgery, radiotherapy and chemotherapy. While the novel strategies may include targeted therapy, electric field treatments and vaccine therapy [6]. Chemotherapy is an intense and cyclic treatment with many side effects such as hair loss, nausea, vomiting and diarrhea [7]. Cyclic dependent kinase inhibitors that have emerged as a potent strategy for the treatment of advanced cancers [8]. The importance of chemotherapy for cure of cancer is increasing, especially with its use as adjuvants to local therapy. Besides, in advanced disease, chemotherapy has an expanding role in efforts to relieve cancer-related symptoms and to prolong life [9].

Cancer remains one of the most feared illnesses and the diagnosis of cancer has a huge psychological impact on the patients and their care-givers [10]. Many cancer patients suffer from psychological problems, such as depression. Cancer patients undergoing chemotherapy, usually experience various symptoms such as depression. Depression worsens during chemotherapy, persists for a long time after the end of chemotherapy, and it is also manifested in the recurrence of the disease [11]. This may interfere with the patient’s ability to cope with the burden of the illness, it may decrease the acceptance of treatment, extend hospitalization [12], reduce the quality of life [13, 14], and increase suicide risk [15]. Furthermore, the depression compromises patient outcomes, resulting in higher rates of mortality [16-18], with estimates as high as a 26% greater mortality rate among patients with depressive symptoms and a 39% higher mortality rate among those with a diagnosis of major depression [19].

The epidemiology of depression among cancer patients was to 23.4% in China [20], 48.7% in Pakistan [21], 17% in Australia [22], 38.2% in Greece [23], 46.5% in Saudi Arabia [24], 67.7% in Rwandan [25], 25% in Addis Ababa-Ethiopia [26], and 58.4% in Gondar-Ethiopia [27]. Different studies showed several factors that are associated with depression such as cancer types [28], female sex [29], old age [14, 30], the duration of cancer [31] and type of treatment. Furthermore, a slightly higher incidence of depression was found among cancer patients who underwent chemotherapy than patients who had not received chemotherapy [32]. Besides, depressive symptoms were more prevalent across patients who were hospitalized compared with patients in the outpatient setting [33].

Regarding depression among cancer patients, most of the studies came from the developed world, and very limited studies addressed populations from low- and middle-income countries. Therefore, this study aimed to assess the prevalence of depression among cancer patients at Tikur Anbessa Specialized Hospital in Ethiopia.

Methods

Study area, design and period

The study was conducted at Tikur Anbessa Specialized Hospital (TASH) which is located in Addis Ababa, which is the capital city of Ethiopia. TASH oncology unit was established in 2015 under the Federal Minister of Health. It is located at Addis Ababa, Lideta Sub–City. The oncology unit provides health services for all cancer patients attending TASH from Addis Ababa city, and different regional states of Ethiopia. The oncology unit at TASH is the largest referral site in the country, providing service to more than 60,000 patients annually. It is the sole oncology referral and the only radiotherapy center in Ethiopia. The cross-sectional study design was employed from 1st March to April 30, 2021.

Source population

All adult cancer patients who had followed up at TASH and treated with chemotherapy have been taken as the source population.

Study population

All adult cancer patients under chemotherapy treatment and follow up service during the data collection period.

Eligibility criteria

Inclusion criteria

All adult cancer patients under chemotherapy and follow up at oncologic clinic in TASH during the data collection period.

Exclusion criteria

Patients who had communication or hearing impairments were excluded.

Sample size calculation and sampling techniques

The required sample size was determined using a single population proportion formula having the following assumptions: value for the 95% CI (Zα/2 = 1.96), the proportion of depression (P = 50%), and margin of error (d = 5%) Then, by adding 10% of study subjects as non-response rate, the final sample size was 422. The study subjects were selected using the systematic random sampling technique after determining the sampling fraction (k = 900/420 = 2) and the first participant was selected using the lottery method.

Study variables

Dependent variable

Depression (Yes/No).

Independent variables

Socio-demographic variables: Age, educational status, marital status, employment, and monthly income.

Psychosocial factors: Social and husband support, emotional violence, physical violence, and sexual violence.

Substance use: Use any substance like khat, alcohol, and cigarette.

Clinical characteristics: Stage of cancer, duration of the illness, comorbidity, type of cancer.

Family history of psychiatric illness: A family history (first-degree relatives) of psychiatric problems.

Data collection tools and procedures

A structured interviewer-administered questionnaire was used to collect data from all participants. Socio-demographic, clinical, and psychosocial factors were assessed using predefined checklists. The social support level was assessed using the Oslo social support scale-3. The Oslo social support-3 consists of three items assessing the level of social support. The sum score ranges from 3 to 14, with high values representing strong levels and low values representing poor levels of social support [34]. Depression was assessed using Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 comprises nine items that can be scored from 0 (not at all) to 3 (nearly every day) and the total score ranges from 0 to 27 to measure depression severity [35, 36]. The standard PHQ9 cut off points 1–4, 5–9, 10–14, 15–19 and greater than or equal to20 was considered as having minimal depression symptoms, minor depression, moderate depression, moderately severe and major depression (severe), respectively. Then, the total depression score was dichotomized, and those cancer patients who scored 10 and above were considered as having symptomatic depression. PHQ-9 is a validated tool in Ethiopia [37].

Data analysis

The collected data were entered into Epi-data version 4.2 and analyzed by SPSS version 25. Bivariate logistic regression was done and, variables with p-value < 0.05 were entered in to a multivariate logistic model. In multivariate logistic regression analysis, adjusted odds ratio with a p-value of < 0.05 was considered statistically significant.

Data quality control

The questionnaire was prepared in English and translated to Amharic and translated back to English before the data collection process. The data collection instrument was pre-tested on 5% of the sample to improve the language clarity and appropriateness of the data collection tools. The estimated time required, and necessary amendments were made after the piloting of the questionnaire. The data were collected by four BSc nursing professionals who were trained for one day on the techniques of data collection, purpose of the study, and ethical considerations. The researcher checked the accuracy, completeness and consistency of questionnaires completed by the data collectors to ensure the quality of data and visited the data collectors as many times as possible to check whether he/she collected the data appropriately. The Amharic version of PHQ-9 is validated in Ethiopia.

Ethical approval and consent to participate

Ethical clearance was obtained from Addis Ababa University, College of Health Sciences, School of Nursing and Midwifery, Research and Ethics Review Committee (IRB protocol: AAU/CHS/NSG/0020). A collaboration letter for data collection was also obtained from TASH. Verbal informed consent was obtained from each participant. The objective of the study and methods of data collection were briefly clarified and explained for each participant, before enrolling any eligible study participants. Then, verbal informed consent was obtained from each participant. As the study does not impose any harm to the participants and from the experience, patients feel their confidentiality is secured more when they give verbal informed consent than written informed consent. To assure confidentiality, a code number was used instead of the participants’ name or identification number.

Operational definitions

Poor social support: cancer patients who scored 3–8 on the (Oslo-3) social support scale during cancer.

Moderate social support: cancer patients who scored 9–11 on the (Oslo-3) social support scale during cancer.

Strong social support: cancer patients who scored 12–14 on the (Oslo-3) social support scale during cancer.

Result

Socio-demographic characteristics of the participants

Four hundred twenty participants were included in the final analysis in this study with a non-response rate of 99.5%. Majority, 243 (57.9%) were female, 220 (52.4%) were in the age between 35 and 51 years and 103 (24.5%) were above the age of 52 years old. The mean and standard deviation age of the participants was 43.6 (SD±12.37) years, over 297 (69%) were married, and 119 (28.3%) completed secondary school education (Table 1).

Table 1

Socio-demographic characteristics of study participants among adult cancer patients at the oncology clinic of TASH, Addis Ababa, Ethiopia, 2021.

Variables	Category	Frequency	Percent
Sex	Female	243	57.9
	Male	177	42.1
Age in years	18–34	97	23.1
	35–51	220	52.4
	≥52	103	24.5
Educational status	Illiterate	45	10.7
	Read and write only	77	18.3
	Primary	94	22.4
	Secondary	119	28.3
	College/university	85	20.2
Marital status	Single	47	11.2
	Married	290	69
	Divorced	16	3.8
	Widowed/r	67	16
Occupation	Private work	106	25.2
	Civil servant	90	21.4
	House wife	116	27.6
	Others	108	25.7
Income	Low	60	14.3
	Medium	113	26.9
	High	247	58.8

Clinical and behavioral characteristics of the study participants

The clinical characteristics of the study participants indicate that; 142 (33.8%) have breast cancer, 120 (28.6%) were on stage 2 cancer, 52 (12.4%) drunk alcohol but now quitted and 33 (7.9%) of participants quitted smoke. Of the total study participants, 6 (1.4%) study participants had a family history of known mental illness and 2(0.5%) had a diagnosis of chronic kidney disease (Table 2).

Table 2

Clinical and behavioral characteristics of study participants among adult cancer patients at oncology clinic of TASH, Addis Ababa, Ethiopia, 2021.

Variables	Category	Frequency	Percent
Stage of cancer	Stage 1	28	6.7
	Stage 2	99	23.6
	Stage 3	120	28.6
	Stage 4	173	41.6
Type of cancer	Breast cancer	156	37.1
	Colon cancer	53	12.6
	Prostate cancer	32	7.6
	NPC	35	8.3
	Cervical cancer	52	12.4
	Lung cancer	33	7.9
	Bladder cancer	12	2.9
	Thyroid cancer	6	1.4
	Hematologic cancer	12	2.9
	Edwing cancer	24	5.7
	Other	5	1.2
Months since diagnosis	<6	203	48.3
	7–12	113	26.9
	>12	104	24.8
Duration since start of chemotherapy	1–3 months	190	45.2
	4–6 months	110	26.2
	>6 months	120	28.6
Family history with known mental illness	Yes	6	1.4
	No	414	98.6
Hypertension	Yes	1	0.2
	No	419	99.8
Diabetes Mellitus	Yes	1	0.2
	No	419	99.8
Chronic kidney disease	Yes	2	0.5
	No	418	99.5
Cardiovascular disease	Yes	1	0.2
	No	419	99.8
Presence of comorbidities	Yes	17	4
	No	403	96
Chewing	Currently chat chewing	1	0.2
	Previously drunker	29	6.9
	Never used	390	92.9
Alcohol	Currently drinker	3	0.7
	Previously drunker	52	12.4
	Never drank	365	86.9
Smoking status	Currently smoker	1	0.2
	Previously smoker	33	7.9
	Never smoke	386	91.9

Note: presence of comorbidities = include hypertension, diabetes mellitus and kidney disease

Abbreviations: SD = standard deviation, chronic illness =, NPC = Naso pharengyal, other type of cancer include = Kaposi sarcoma, adenocarcinoma, and oropharia cancer

Psychosocial factors (in the last 6 months) of cancer patients

From the total of participants, 53 (12.6%) responded that their family or close relatives had died and 30 (7.1%) participants responded as having died a spouse, parent, or child during the disease. 125 (29.8%) responded to having major financial crisis. 20(4.8%) responded to being sacked from their job (Table 3).

Table 3

Psychosocial factors (in the last 6 months) of adult cancer patients receiving chemotherapy at TASH, Addis Ababa, Ethiopia, 2021.

Variable	Category	Frequency	Percent
Serious illness or injury during cancer	Yes	7	1.7
	No	413	98.3
Close relative serious illness or injury or assault	Yes	9	2.1
	No	411	97.9
Died spouse, parent or child	Yes	30	7.1
	No	390	92.9
Died family or close relatives	Yes	53	12.6
	No	367	87.4
	Yes	125	29.8
Major financial crisis
	No	295	70.2
Sacked from job	Yes	20	4.8
	No	400	95.2
Unemployed/not able to work	Yes	41	9.8
	No	379	90.2
Separation due to marital difficulty	Yes	11	2.6
	No	409	97.4
Broken off a steady relationship	Yes	11	2.6
	No	409	97.4
Serious problems with close friend, neighbor /relative	Yes	19	4.5
	No	401	95.5
Lost/stolen property which mattered a lot	Yes	20	4.8
	No	400	95.2
Any problems with police/court	Yes	11	2.6
	No	409	97.4
Trauma by your wife or husband	Yes	6	1.4
	No	414	98.6
Forced sexual activity	Yes	1	0.2
	No	419	99.8

Social support among cancer patients

Of the total participants, 94 (22.4%), 207 (49.3%) and 119 (28.3%) had poor, moderate and strong social support, respectively (Fig 1).

Fig 1

Social support of adult cancer patients.

Prevalence of depression among cancer patients

The overall prevalence of depression among adult cancer patients was 33.1% (95% CI = 0.2858, 0.3761) (Fig 2).

Fig 2

Prevalence of depression among adult cancer patients.

Minimal symptoms of depression, minor depression, moderate depression, moderate severe depression, and severe depression were found to be 272 (64.8%), 9 (2.1%), 104 (24.8%), 28 (6.7%), and 7 (1.7%), respectively. A higher prevalence of depression was seen among patients with nasopharyngeal cancer (NPC) 51%, followed by thyroid cancer 50%, and breast cancer 42% (Fig 3).

Fig 3

Depression among each type of cancer.

Factors associated to depression

In bivariate logistic regression analysis, education, income, type of cancer, the stage of cancer, serious illness or assault happened to close relatives, major financial problem, unemployed, sacked from a job, a serious problem with a close friend or neighborhood, having some problems with the police or courts, and social support were significantly associated with depression (p <0.05). When these variables were entered and analyzed in multivariate logistic regression, education, colon cancer, prostate cancer, cervical cancer, stage of cancer, unemployed and sacked from job were significantly associated with depression.

The results showed that participants who completed their primary education were less likely to develop depression than those who had no formal education (AOR: 0.414, 95% CI = 0.206–0.829). Additionally, patients with colon cancer were less likely to develop depression as compared to breast cancer (AOR: 0.364, 95% CI = 0.156–0.847). Besides, patients with prostate cancer and cervical cancer were less likely to develop depression compared to patients with breast cancer (AOR: 0.184, 95% CI = 0.064–0.525; AOR: 0.334, 95% CI = 0.148–0.752, respectively). Patients with Stage four cancer were seven times more likely to develop depression compared to patients with stage one (AOR: 7.444, 95% CI = 1.943–28.523). Being unemployed was two times more likely risk of developing depression compared to being employed (AOR: 2.263, 95% CI = 1.043–4.913), and patients sacked from job were three times more likely to develop depression compared to no sacke from job (AOR: 3.404, 95% CI = 1.049–11.042) (Table 4).

Table 4

Bivariate and multivariate logistic regression analysis of independent factors to depression among cancer patients at the oncology clinic of TASH, Addis Ababa, Ethiopia, 2021.

Variables	Category	Depression		COR(95%CI)	AOR(95%CI)
		No (n, %)	Yes (n, %)
Education	No formal education	70(57.4)	52(42.)	1	1
	Primary	71(75.5)	23(24.5)	0.436(0.241–0.788)*	0.414(0.206,0.829)*
	Secondary	83(69.7)	36(30.3)	0.584(0.343–0.993)*	0.538(0.279,1.037)
	Higher	57(67.1)	28(32.9)	0.661(0.371–1.178)	0.621(0.291,1.325)
Income	Low	32(53.3)	28(46.7)	1.827(1.03,3.239)*	1.211(0.573,2.56)
	Medium	82(72.6)	31(27.4)	0.789(0.483–1.29)	0.791(0.425,1.473)
	High	167(67.6)	80(32.4)	1	1
Type of cancer	Breast cancer	90(57.7)	66(42.3)	1	1
	Colon cancer	39(73.6)	14(26.4)	0.49(0.246,0.974)*	0.364(0.156,0.847)*
	Prostate cancer	26(81.3)	6(18.8)	0.315(0.123,0.808)*	0.184(0.064,0.525)*
	NPC	17(48.6)	18(51.4)	1.444(0.692,3.011)	1.408(0.609,3.256)
	Cervical cancer	41(78.8)	11(21.2)	0.366(0.175,0.765)*	0.334(0.148,0.752)*
	Lung cancer	25(75.8)	8(24.2)	0.436(0.185,1.028)	0.407(0.154,1.076)
	Bladder cancer	8(66.7)	4(33.3)	0.682(0.197,2.36)	0.775(0.196,3.065)
	Thyroid cancer	3(50)	3(50)	1.364(0.267,6.97)	1.291(0.19,8.791)
	Hematologic	10(83.3)	2(16.7)	0.273(0.058,1.286)	0.559(0.098,3.184)
	Edwing cancer	17(70.8)	7(29.2)	0.561(0.22,1.431)	0.617(0.215,1.766)
	Other	5(100)		-	-
Stage of cancer	Stage 1	25(89.3)	3(10.7)	1	1
	Stage 2	81(81.8)	18(19.2)	1.852(0.504,6.808)	1.893(0.461,7.764)
	Stage 3	85(70.8)	35(29.2)	3.431(0.973,12.104)	3.558(0.904,14.009)
	Stage 4	90(52)	83(48)	7.685(2.237,26.402)*	7.444(1.943,28.523)*
Serious illness, injury or assault happened to a close relatives	Yes	35(51.5)	33(48.5)	2.188(1.291,3.707)*	1.9(0.958,3.771)
	No	246(69.9)	106(30.1)	1	1
A major financial crisis	Yes	80(56.7)	61(43.3)	0.509(0.333,0.777)*	1.597(0.965,2.642)
	No	201(72)	78(28)	1	1
Unemployed	Yes	16(39)	25(61)	3.632(1.868,7061)*	2.263(1.043,4.913)*
	No	165(69.9)	114(30.1)	1	1
Sacked from job	Yes	5(27.8)	13(72.2)	5.695(1.988,16.319)*	3.404(1.049,11.042)*
	No	276(68.7)	126(31.3)	1	1
A serious problem with a close friend, neighborhood	Yes	7(36.8)	12(63.2)	3.699(1.422, 9.617)*	3.177(0.872,11.571)
	No	274(68.3)	127(31.7)	1	1
Have you had any problems with the police or courts	Yes	4(36.4)	7(63.6)	3.672(1.057,12.765)*	0.924(0.164,5.199)
	No	277(67.7)	132(32.3)	1	1
Social support	Poor	91(56.9)	69(43.1)	1.896(1.106,3.248)*	1.641(0.851,3.165)
	Moderate	120(74.1)	42(25.9)	0.875(0.499,1.535)	1.196(0.622,2.3)
	Strong	70(71.4)	28(28.6)	1	1

NPC: Naso Pharyngeal Cancer; N: number; COR = Crud Odds ratio; AOR = Adjusted Odds Ratio; CI = Confidence Interval; %: percent

* = statistically significant by univariate logistic regression

** = statistically significant by multivariate logistic regression

Discussion

The overall prevalence of depression among adult cancer patients was 33.1% in this study. This finding was higher than the results of a studies conducted in Jordan-23.4% [38], India-22% [39], Iran-21.3% [31], Asia-29.6% [40], German-24% [41] and Ethiopia-Addis Ababa-25.0% [26]. However, it was lower than the findings of a study conducted in China- 66.7% [42], Ethiopia-Gondar-70.86% [43], Greece-38.2% [23], German 36.9% [44], Ethiopia 36.9% [45], and Rwanda 67.7% [46]. The variation might be due to differences in instruments to assess depression, criteria to define depression, and included cancer populations with respect to cancer type, stage and treatment modality.

Available data also suggest that cancer may increase patients’ susceptibility to depression in several ways. To mention some, a reaction to a severe diagnosis and the forthcoming deterioration of health status may constitute a risk factor for depression; treatment with immune response modifiers and chemotherapy regimens, and experiencing of metabolic and endocrine alterations, chronic pain and extensive surgical interventions, may represent additional contributing factors [47, 48].

Patients who are at a high risk of depression require special attention and a strong support system. psychological problems hinder their ability to cope with treatment and symptoms, as well as recovery from chemotherapy side effects and cancer impact [49]. Depression in patients with cancer can be prevented and prophylactic treatment should be administered during oncological treatment [50]. The treatment of depression must be started at an early stage. It can take a long time to make patients aware of the psychological nature of their difficulties, having this consideration, encourage them to request a psychological consultation or to accept the prescription of psychotropic or, in particular, antidepressant medicaments [51].

The current study found several associated factors for depression among cancer patients in Ethiopia. Those associated factors were primary education, unemployment, sacked from jobs, colon cancer, prostate cancer, cervical cancer and cancer stage. Study participants who completed their primary education were less likely to develop depression than who had no formal education. This finding was in a line with the findings of studies conducted in Ethiopia [21, 26, 43]. Education may offer opportunities for developing interventions to reduce the disease burden of depression. Low education levels are linked with depression and that higher levels of education play a preventive role against depression [21]. Being unemployed was found to have 2.2 times a more likely risk to develop depression compared to being employed, which is supported by other studies [43, 52]. Patients sacked from job were 3.4 times more likely to develop depression compared to no sack from job. Having no or low education level, unemployed status, and being sacked from jobs, negatively influence depression symptoms. These often make the adaption process of psychological disorders to be longer and harder [53]. The experience of being diagnosed with cancer could become a source of distress in addition to the disruption in the work role. Failure to remain in employment could deprive an individual from social contact and well-being.

Patients who had colon, prostate and cervical cancer were less likely to have depression compared with those with breast cancer. This finding was similar in other studies [54]. The possible explanation for this occurrence might be increased worriedness of patients after breast cancer diagnosis, to shortened survival time, recurrence and metastasis. Furthermore, female patients face impaired body image and decreased quality of sexual life caused by surgery and other treatments. Therefore, compared with other malignant tumors, the incidence of depression and other psychiatric symptoms in breast cancer patients are higher, which is also closely related to the lack of female secondary characteristics and physical symptoms such as nausea, vomiting, fatigue, hair loss, and insomnia caused by chemotherapy [55].

Moreover, patients with stage four had 7.4 times more likely at risk of developing depression compared to patients with stage one. Similar findings have been found in other studies [14, 46]. This might be due to when the stage is advanced, patients may fear or stress. Studies found that individuals diagnosed at an advanced stage have a higher risk of developing depression compared with those diagnosed at an early stage [14, 56]. Patients with advanced-stage cancer generally have a greater need for supportive care, due to poor physical functioning, a greater symptom burden, and higher levels of distress, and depression than other cancer patients [57]. Earlier and more intensive supportive care for patients with cancer reduces symptom burden and may prolong life for patients with advanced disease [58]. For managing their distress, pharmacotherapy and psychotherapy are effective for managing depression among advanced cancer patients [59].

The preventive strategies toward the risk factors of depression include education and counselling programs that must be designed and planned according to the patient’s wishes and learning needs [60]. The current study is conducted in light with some limitations. First, some of the depression symptoms may have been due to the cancer itself or its treatment rather than due to depression.

Conclusion

Depression is found to be a major public health problem for adult cancer patients in Ethiopia. Those cancer patients who had unemployed status, sacked from jobs, and stage IV cancer were most likely to develop depression, whereas patients having completed primary education, colon, prostate and cervical cancer were less likely to have depression. To reduce the prevalence of depression among cancer patients, designing strategies and special attention are needed to bring changes in the psychological status of patients in advanced disease stage.

Sociodemographic questions.

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Clinical and behavioral characteristics of questions.

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Psychosocial questions.

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Socila support questions.

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Tools used to assess depression.

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Data collection tool.

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4 Apr 2022

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The author presented an original article on ‘Prevalence of depression and associated factors among adult cancer patients receiving chemotherapy during the era of COVID-19 in Ethiopia. A Hospital based cross sectional study’. The manuscript needs to be improved regarding the following aspects.

• Cancer chemotherapy should be described in detail to strengthen your research study moreover, overall associated factors for cancer risk should also be included in the introduction part, Biomed Pharmacother. 2021; 143: 112119. https://doi.org/10.1016/j.biopha.2021.112119

• In the discussion section, discuss more details of the results and their outcome risks and preventive strategies.

• More description is required to explain the association between key points and the conclusion.

• In this article not a single graphical representation has been included, add approximately 3 to 4 figures or graphs to strengthen your research manuscript.

• There are a few formatting mistakes, for this deeply review the article.

• Many references are missing or inconsistent in format.

• There are some grammatical mistakes in the manuscript, such as verbs and prepositions. The manuscript needs extensive review by an author.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

24 Apr 2022

PONE-D-22-06018

Prevalence of depression and associated factors among adult cancer patients receiving chemotherapy during the era of COVID-19 in Ethiopia. A Hospital based cross sectional study

PLOSONE

Dear Dr. Belete,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Response: Dear editor, thank you very much for allowing us to revise our manuscript. We have tried to respond to each concern as much as possible. We have submitted a revised version of the manuscript.

I have received the reports from our advisors on your manuscript which you submitted to PLOS ONE.

Based on the comments received, I feel that your manuscript could be reconsidered for publication should you be prepared to incorporate major revisions. When preparing your revised manuscript, you are asked to carefully consider the reviewer comments below and submit a list of responses to the comments.

Author response: Dear editor, thank you for considering our manuscript publication. We have addressed the points raised by the reviewer and editors.

Editor Comments: The paper should be checked by a professional speaker of English before complete acceptance.

Author response: Dear editor, thank you very much. We have tried to edit the manuscript and also we used the online Grammarlly using the following links: https://www.grammarly.com/

Please submit your revised manuscript by May 19 2022 11:59 PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Author response: Dear editor, thank you. We have submitted per the due date.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Author response: Dear editor, thank you. We have included ‘Response to Reviewers', 'Revised Manuscript with Track Changes’, and ‘Manuscript’ separately.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

Author response: Dear editor, thanks for allowing us to update the financial disclosure. We have added it to the cover letter. Thanks for the suggestion for guidelines for figures.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial email&utm_source=authorletters&utm_campaign=protocols.

Author response: Dear editor, thank you for recommending depositing the laboratory protocols in protocols.io. But it is not applicable

We look forward to receiving your revised manuscript.

Kind regards,

Muhammad Sajid Hamid Akash

Academic Editor PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Author response: Dear Editor, we saw the link you invited me and I made corrections to the manuscript style to meet the requirement of PLOS ONE.

2. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services. If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Author response: Dear editor, thank you for your suggestion.

Upon resubmission, please provide the following:

The name of the colleague or the details of the professional service that edited your manuscript

Author response: Dear Editor, we edit the manuscript by using an online grammar checker.

A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

Author response: Dear Editor, we have included manuscripts that contain track changes and uploaded them as manuscript track changes.

A clean copy of the edited manuscript (uploaded as the new *manuscript* file)”

Author response: Dear Editor, thank you. We have included a clean copy of the edited manuscript and uploaded them as a manuscript file.

3. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information.

Author response: Dear Editor, 1) consent was informed 2) the consent obtained was verbal informed consent. Detail of the study’s objective, method of data collection, and ethical concern were explained to potential participants, and they were requested to participate in the study voluntarily. For volunteer participants, data collectors tick the right sign in front of I agree, then continue interviewing the participant. There were no minors in this study, all were adults who can themselves give consent after understanding what was explained about the study. The study participants gave verbal consent to use their medical cards.

4. Thank you for stating the following financial disclosure:

"The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

Author response: Dear Editor, sorry for making confused. It is a technical error this work had not received any form of support. All cost is covered by author.

State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

Author response: Dear Editor, again sorry. This study did not receive any form of support. Therefore, there is no funder.

b) If any authors received a salary from any of your funders, please state which authors and which funders.

Author response: Dear Editor, since no funder was participated so no author is received salary from funders.

d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Author response: Dear Editor, the authors received no specific funding for this work.

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

Author response: Dear Editor, thank you very much. The amended statement is within the cover letter.

5. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

[Note: HTML markup is below. Please do not edit.]

Author response: Dear Editor, thank you for your recommendation. Already I have an ORCID id

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Author response: Dear reviewer, we have tried to modify it. See the revised track changes.

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Author response: Dear reviewer, thank you very much.

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Author response: Dear reviewer, thank you

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Author response: Dear reviewer, thank you very much

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Response: Dear editor, thank you very much. We have tried to answer the reviewer’s feedback and question as much as we can.

Reviewer #1: The author presented an original article on ‘Prevalence of depression and associated factors among adult cancer patients receiving chemotherapy during the era of COVID-19 in Ethiopia. A Hospital based cross sectional study’. The manuscript needs to be improved regarding the following aspects.

• Cancer chemotherapy should be described in detail to strengthen your research study moreover, overall associated factors for cancer risk should also be included in the introduction part, Biomed Pharmacother. 2021; 143: 112119. https://doi.org/10.1016/j.biopha.2021.112119

Author response: Dear reviewer, thank you for your recommendation. As per your recommendation, we have made an amendment to the revised manuscript.

• In the discussion section, discuss more details of the results and their outcome risks and preventive strategies.

Author response: Dear reviewer, thank you very much. We have tried to address all the points you raised in the revised manuscript.

• More description is required to explain the association between key points and the conclusion.

Author response: Dear reviewer, we have tried to add more description in the discussion part that links to a conclusion.

• In this article not a single graphical representation has been included, add approximately 3 to 4 figures or graphs to strengthen your research manuscript.

Author response: Dear reviewer, thank you very much for your effort to see each part of our work. According to your suggestion, we add 3 figures to the revised manuscript.

• There are a few formatting mistakes, for this deeply review the article.

Author response: Dear reviewer, we review deeply and modification was done in the revised manuscript.

• Many references are missing or inconsistent in format.

Author response: Dear reviewer, I made corrections as per your comment.

• There are some grammatical mistakes in the manuscript, such as verbs and prepositions. The manuscript needs extensive review by an author.

Author response: Dear reviewer, as per your comment I revise the manuscript for grammatical and spelling errors. The corrections are highlighted in the document entitled “revised manuscript with track changes”.

________________________________________

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Author response: Dear editor, thank you for your suggestion. We used the link that you invite me.

Submitted filename: Response to reveiwer.docx

Click here for additional data file.

2 Jun 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Muhammad Sajid Hamid Akash

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The author presented an original article on “Prevalence of depression and associated factors among adult cancer patients receiving chemotherapy during the era of COVID-19 in Ethiopia. Hospital-based cross-sectional study”. The manuscript needs to be improved regarding the following aspects.

• The literature part is not up-to-date as I recommended you make changes in your manuscript that will strengthen your work. Again, I asked you to update the literature section by briefly explaining the cancer-associated risk factors and some of its novel therapeutic interventions. Biomed Pharmacother. 2021; 143: 112119. https://doi.org/10.1016/j.biopha.2021.112119. Biomed Pharmacother. 2018; 107: 1326-41. https://doi.org/10.1016/j.biopha.2018.08.116.

• The figures you have added are quite simple, more work is needed on graphics. Kindly revise them (figure1 and figure 2) with more creativity and diversity.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

5 Jun 2022

PONE-D-22-06018R1

Prevalence of depression and associated factors among adult cancer patients receiving chemotherapy during the era of COVID-19 in Ethiopia. Hospital-based cross-sectional study

PLOS ONE

Dear Dr. Belete

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Response: Thank you very much for allowing us to revise our manuscript again. We have tried to response each concerns as much as possible. We have submitted a revised version of the manuscript.

I have received the reports from our advisors on your manuscript which you submitted to PLOS ONE.

Based on the comments received, I feel that your manuscript could be reconsidered for publication should you be prepared to incorporate major revisions.

When preparing your revised manuscript, you are asked to carefully consider the reviewer comments below and submit a list of responses to the comments.

Response: Again thank you very much. We will provide a list of response.

Editor Comments: There is a huge list of grammatical mistakes and syntax errors. The paper should be checked by a professional speaker of English before complete acceptance.

Response: we have extensively edited the manuscript for language usage, spelling, and grammar before submitting the revised version. The formatting of the text and document (text sizes and grammatical errors) were also edited. We have edited using the free editing chance at Trinka. Using the following link: https://www.trinka.ai

Additionally, we have extensively edited the manuscript by a professional language editor, (English-language speaker thoroughly edited the manuscript for language usage, spelling, and grammar) before submitting the revised version. His name is Dr. Menakath Menon.

Please submit your revised manuscript by Jul 17 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Response: we will provide on due date.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Response: Thank you. We have included ‘Response to Reviewers', 'Revised Manuscript with Track Changes and Manuscript separately

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

Response: thank you for reminding us on financial disclosure. The updated financial disclosure is given in the cover letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols

Response: thank you for your suggestion, but we haven’t any form of laboratory protocols.

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Response: sorry for inadequately addressed your concern. However, in the current version, all of your concern is updated as per your comments.

________________________________________

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Response: in fact your concern is appreciated. We have made extensive modification in the revised manuscript.

________________________________________

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Response: Thank you.

________________________________________

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Response: Thank you

________________________________________

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Response: Thank you.

________________________________________

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Response: thanks .We tried to address each and every question/concern step by step

Reviewer #1: The author presented an original article on “Prevalence of depression and associated factors among adult cancer patients receiving chemotherapy during the era of COVID-19 in Ethiopia. Hospital-based cross-sectional study”. The manuscript needs to be improved regarding the following aspects.

• The literature part is not up-to-date as I recommended you make changes in your manuscript that will strengthen your work. Again, I asked you to update the literature section by briefly explaining the cancer-associated risk factors and some of its novel therapeutic interventions. Biomed Pharmacother. 2021; 143: 112119. https://doi.org/10.1016/j.biopha.2021.112119. Biomed Pharmacother. 2018; 107: 1326-41. https://doi.org/10.1016/j.biopha.2018.08.116.

Response: Thank you for providing the most updated article. As per your suggestion we made modification in the revised manuscript.

• The figures you have added are quite simple, more work is needed on graphics. Kindly revise them (figure1 and figure 2) with more creativity and diversity.

Response: we tried to make more attractive.

________________________________________

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

________________________________________

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Response: thank you

Submitted filename: authore response 2.docx

Click here for additional data file.

8 Jun 2022

Prevalence of depression and associated factors among adult cancer patients receiving chemotherapy during the era of COVID-19 in Ethiopia. Hospital-based cross-sectional study

PONE-D-22-06018R2

Dear Dr. Belete,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Muhammad Sajid Hamid Akash

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

17 Jun 2022

PONE-D-22-06018R2

Prevalence of depression and associated factors among adult cancer patients receiving chemotherapy during the era of COVID-19 in Ethiopia. Hospital-based cross-sectional study

Dear Dr. Belete:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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