Clarifications and perspectives on mental health assessment during the COVID-19 pandemic

First of all, we would like to express our satisfaction with the interest that our article¹ has generated, particularly because it has elicited a comment from the esteemed Josef Finsterer.² We thank Prof. Finsterer for his observations, which provide an opportunity to deepen and enrich the discussion on the results of our research.

We must begin by reiterating that our research was conducted amid the COVID-19 pandemic, during which social distancing was mandatory in Portugal. In this context, electronic data collection, a practice widely adopted by researchers worldwide, and which made possible numerous studies published in high-impact scientific journals such as this one,³ proved to be both appropriate and necessary. However, we understand the author's concern and view it as a timely invitation to reflect on methodological practices now largely accepted by the scientific community, such as digital data collection. This methodological option is supported by a robust empirical basis confirming the psychometric equivalence between electronic and paper versions of self-report instruments.^4-9 It should also be noted that the present study is part of a broader longitudinal investigation which verified the temporal invariance of the instruments used, attesting to their reliability and psychometric adequacy.

Regarding the difficulty in separation between the constructs of interest, we recognize the complexity involved. However, it does not seem appropriate to disregard the solid theoretical-empirical body of evidence that supports the DASS-21 scale, designed precisely to differentiate these constructs, avoiding overlap between their subscales.¹⁰ The proposed three-factor structure has been extensively validated, demonstrating consistency across large samples,¹¹ cross-cultural invariance,¹² and validity in clinical and non-clinical populations.^13,14 In addition, we sought to go beyond the traditional variable-centric approach by integrating a person-centered perspective through Latent Profiling. This approach allowed us to identify how the different constructs interact with each other in the various groups we analyzed. It is possible that this strategy was not explicit enough in the article, which may have limited the perception of its scope. Ultimately, the potential overlap observed between constructs may be interpreted as an expression of transdiagnostic processes, which consist of mechanisms common to multiple forms of psychological distress,¹⁴ given the relatively similar symptomatology often observed among the psychopathologies.

Regarding the heterogeneity of the groups we studied, we acknowledge the internal diversity both among participants with a history of psychiatric illness and among immigrants. However, the aim of our study was not to explore the specificities of each subgroup but rather to analyze, from an intersectional perspective, how social axes of differentiation, such as immigration, minority membership, and psychiatric diagnosis, influence mental health. This approach aims to understand broader structural dynamics without dwelling on the particular identity elements of each group.

Concerning stress, it is essential to emphasize that this construct was measured using a widely validated and internationally recognized instrument (DASS-21), which defines its operationalization in a clear, replicable manner. Although we realize that stress can have multiple manifestations and origins, the approach we adopted was consistent with the defined psychometric parameters.

We acknowledged from the outset that the unequal gender distribution was a limitation of the study. However, we conducted statistical adjustment for the impact of this variable on our analyses and the results indicated that, although gender influences some dimensions, it does not compromise the robustness of the identified patterns.

Furthermore, aware of the limitations of the cross-sectional design and the correlational nature of our analyses, throughout the article we avoided definitive conclusions and instead limited ourselves to describing the observed empirical patterns and discussing their possible theoretical and practical implications.

Finally, we consider analyzing more homogeneous groups a valid suggestion which may be explored in future research. However, we reiterate that the heterogeneity of the groups we analyzed precisely reflects the complexity of the social reality that we sought to understand through an intersectional approach.

Once again, we thank Prof. Finsterer, who, as a commentator, has contributed expressively to enriching the scientific debate. We hope this dialogue will enrich the scientific debate and contribute to advancing knowledge in mental health.

Disclosure

The authors declare no conflicts of interest.