{'fraction_non_alphanumeric': 0.02773892773892774, 'fraction_numerical': 0.008236208236208237, 'mean_word_length': 5.017297802711547, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Climate change, climate-related disasters and mental disorder in low- and middle-income countries: a scoping review

Introduction Climate change and climate-related disasters adversely affect mental health. Low- and middle-income countries (LMICs) are particularly vulnerable to the impacts of climate change and climate-related disasters and often lack adequate mental healthcare infrastructure. We used the scoping review methodology to determine how exposure to climate change and climate-related disasters influences the presence of mental disorders among those living in LMICs. We also aimed to recognise existing gaps in this area of literature. Methods This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist. To identify relevant studies, we searched five electronic databases (MEDLINE, EMBASE, Global Health, APA PsycInfo and Sociological Abstracts) from 1 January 2007 to 31 December 2019. We also searched the grey literature. Included studies had an adult-focused LMIC population, a climate change or climate-related disaster exposure and a mental disorder outcome. Relevant study information was extracted and synthesised. Results Fifty-eight studies were identified, most of which (n=48) employed a cross-sectional design. The most commonly studied exposure–outcome combinations were flood-related post-traumatic stress disorder (PTSD) (n=28), flood-related depression (n=15) and storm-related PTSD (n=13). The majority of studies identified a positive exposure–outcome association. However, few studies included a baseline or comparator (ie, unexposed) group, thereby limiting our understanding of the magnitude or nature of this association. There was also great heterogeneity in this literature, making studies difficult to pool or compare. Several research gaps were identified including the lack of longitudinal studies and non-uniformity of geographic coverage. Conclusion To our knowledge, this was the first scoping review to investigate the relationship between climate change and climate-related disaster exposures and mental disorder outcomes in LMICs. Our findings support the need for further research, but also highlight that mental health should be a priority within LMIC climate change policy considerations.


GENERAL COMMENTS
The study attempted to summarise the available literature for impacts of climate change to mental disorders in LMICs. This was an interesting paper to read. However, there were fundamental problems with the scoping review. One is the use of "climate change" when the exposures in the included studies did not explicitly associated them with climate change. For example, the study of Ashok 2019 and Bandla 2019 uses a major flood event as exposure but did not do any analysis that these floods are caused by climate change. I did not review the rest of the included studies, but the authors could check them again. I believe a good example of a study that can be included is Carleton 2017. Furthermore, concluding that there is positive association between climate change exposures and mental disorders may be inappropriate given that they were not associated with climate change (and their presumably very wide heterogeneity). I think it may be better to consider changing the name of the exposures (e.g. climaterelated) and be more considerate in properly grouping them (rather than pooling them as "climate change exposures" like in the conclusion).
Another major issue is the mismatch between the objective and the results. If the goal of the authors is to "conceptualise the relationship between climate change and adult mental disorders in LMICs." or answer the question "how does exposure to climate change influence the presence of mental disorders among those living in LMICs?" (please be consistent with your terminologies), just summarising the quantitative findings of each study is not enough. The discussions in these studies could be a better source of information to properly "conceptualise" such pathways. I believe scoping reviews are meant to be broader and not be like any other systematic review which reports a very specific quantitative measure.
Some minor comments are: 1. In page 4, it may be better to not include the second and third bullets because they are common in scoping reviews anyways. 2. The population criterion is confusing: "Adults (mean age over 18 years)". Why mean age? So adolescents can be in the study sample size as long as the mean age is 18 years? 3. In page 8 line 52, please be consistent with the term "irrelevance screen" with the what was mentioned in the methods. 4. In page 9, "backward and forward snowballing" was not explained in the methods. 5. Table 2 and Supplementary Material 1 are not the same and should be consistent. Diurnal temperature is not extreme temperature. Displacement could've been categorised as flooding.
There is none mentioned about rainfall/precipitation in Supplemental Material 1. 6. Southeast Asia and South Asia should be switched over. They do not represent the countries stated in the results. 7. In page 17 last paragraph, stating processes related to systematic reviews can be removed since the authors used scoping review.

Reviewer Comment Response
Reviewer #1 None Reviewer #2 One is the use of "climate change" when the exposures in the included studies did not explicitly associated them with climate change. For example, the study of Ashok 2019 and Bandla 2019 uses a major flood event as exposure but did not do any analysis that these floods are caused by climate change. I did not review the rest of the included studies, but the authors could check them again. I believe a good example of a study that can be included is Carleton 2017. Furthermore, concluding that there is positive association between climate change exposures and mental disorders may be inappropriate given that they To address this issue, we have differentiated between two exposure types: climate change and climate-related disasters. These terms are differentiated in the Eligibility Criteria section. Climate-related disaster exposures represent the direct effects of climate change (psychological trauma due to experiences of climaterelated disasters such as flooding, wildfires, and heatwaves). Climate change exposures represent the indirect effects of climate change (mental health problems associated with broader climate changerelated events such as gradual temperature increase and displacement). We have made this change throughout the manuscript (wherever climate change exposures were referenced). Further, in Supplementary were not associated with climate change (and their presumably very wide heterogeneity). I think it may be better to consider changing the name of the exposures (e.g. climate-related) and be more considerate in properly grouping them (rather than pooling them as "climate change exposures" like in the conclusion).
Material 4 we have also identified each study by its exposure type.
By making these changes, we have avoided pooling all exposures as "climate change", therefore making it more clear for readers. Please note that we also chose to remove the final limitation in the Strengths and Limitations section as we believe that it is no longer relevant after separating the two exposure types.
Another major issue is the mismatch between the objective and the results. If the goal of the authors is to "conceptualise the relationship between climate change and adult mental disorders in LMICs." or answer the question "how does exposure to climate change influence the presence of mental disorders among those living in LMICs?" (please be consistent with your terminologies), just summarising the quantitative findings of each study is not enough. The discussions in these studies could be a better source of information to properly "conceptualise" such pathways. I believe scoping reviews are meant to be broader and not be like any other systematic review which reports a very specific quantitative measure.
Thank you for your suggestion. We agree that our study objectives were not entirely reflective of our scoping review methodology.
We have re-written our primary objective: "to determine how exposure to climate change and climate-related disasters influences the presence of mental disorders among those living in LMICs". We have also added a secondary objective: "to recognize existing gaps in this area of literature". We believe that this secondary objective is in more line with the purpose of a scoping review. In addition, these objective statements are now consistent between the abstract and the main text.
In page 4, it may be better to not include the second and third bullets because they are common in scoping reviews anyways.
Thank you for your suggestion. We have opted to keep these bullet points in the Article Summary given that they do represent important strengths/weaknesses of our study.
To provide readers with some additional context, we have highlighted that both of these points are common in the conduct of a scoping review. In the second point, we explained that the review was conducted using PRISMA standards. In the third point, we acknowledged the English-language limitation as commonplace for scoping reviews.
The population criterion is confusing: "Adults (mean age over 18 years)". Why mean age? So adolescents can be in the study sample size as long as the mean age is 18 years?
Our review focused primarily on adults. Many studies in this area of literature included both adults and children but had adults as quite a large proportion of their sample (please see the following study as an example: 10.1017/dmp.2015.64). Because these types of studies focused largely on adults, we felt that they were important to include in our review.
Therefore, we chose to use the mean age as our inclusion criterion. To make this clearer for readers, we have added our explanation of this decision into the Eligibility Criteria section and we have specified in Table 1 that the study population for inclusion was adult-focused, instead of exclusively adults.
In page 8 line 52, please be consistent with the term "irrelevance screen" with the what was mentioned in the methods.
We have updated the terminology in this sentence so that it better reflects the methods; the term "irrelevance screen" has been changed to "single-author relevancy screen".
In page 9, "backward and forward snowballing" was not explained in the methods.
Thank you for pointing this out. We explained backward and forward snowballing in the methods but did not label it as such. We have now clarified this in the second paragraph of the Information Sources and Search Strategy section. Southeast Asia and South Asia should be switched over. They do not represent the countries stated in the results.
Thank you very much for pointing this out. We have corrected this error throughout the manuscript and in Supplementary Material 4.
In page 17 last paragraph, stating processes related to systematic reviews can be removed since the authors used scoping review.
We have removed the sentences in this paragraph referencing processes related to systematic reviews.

GENERAL COMMENTS
The authors responded to the comments adequately. Some minor comments/suggestions are: 1. Consider presenting results of some climate change-related studies rather than plainly focusing on disasters and meteorological exposures (i.e. temperature and diurnal temperature) 2. Page 16, line 14: please add a reference on the phrase "diurnal temperature range, a known indicator of climate change" 3. In supplemental material 4, please edit the heading "Main Findings (on the association between climate change and mental disorders)" to "...climate change or climate-related disasters...".

Reviewer Comment Response
Reviewer #2 Consider presenting results of some climate change-related studies rather than plainly focusing on disasters and meteorological exposures (i.e. temperature and diurnal temperature) Thank you for your suggestion. We have added a description of two climate change-related studies in the South Asia section of the results. The exposure in both of these studies was displacement, which is considered a broader effect of climate change.
We have also added a sentence to the Eligibility Criteria section of the methods to further describe the challenges of capturing climate change-related exposures.
Page 16, line 14: please add a reference on the phrase "diurnal temperature range, a known indicator of climate change" We have added a reference to support this statement.
In supplemental material 4, please edit the heading "Main Findings (on the association between climate change and mental disorders)" to "...climate change or climate-related disasters...".
Thank you for pointing this out, it has been corrected.