PONE-D-20-08001

Perceived learning difficulty associates with depressive symptoms and substance use among students of higher educational institutions in North Western Ethiopia: A cross sectional study

PLOS ONE

Dear Dr. Bitew,

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I could not get a comment from the Second reviewer unfortunately. But I think that the authors should address the methodological points the first reviewer pointed out.

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Yutaka J. Matsuoka, MD, PhD

Academic Editor

PLOS ONE

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that of the authors and were not that of the funder.

TB is also financially supported by the Africa Mental Health Research Initiative (AMARI) within the

DELTAS Africa Initiative [DEL-15-01] as a post-doctoral fellow. The DELTAS Africa Initiative is an

independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating

Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development

Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust [DEL-15-

01] and the UK government. TB was also supported financially by Debre Markos University."

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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

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

Reviewer #1: No

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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: No

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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: No

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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 authors aimed to investigate the prevalence and risk factors of depressive symptoms and substance use among university students in North-Western Ethiopia. Focusing on depression and substance use is quite significant both from a clinical and public health perspective. However, several points should be critically considered.

[Major comments]

The authors assert the importance of clinical depression and substance abuse; however, this cross-sectional study assesses the level of depressive symptoms and substance use that compromise with a flaw, limiting the clinical relevance which needs to be considered.

The authors report that the prevalence of mild levels of depressive symptoms to be about 30%, and that of major depressive symptoms to be about 40%. However, the mean (SD) PHQ-9 score of the sample is not given, which makes it ambiguous whether the sample has marked depression symptoms that may cause noticeable problems in relationships with others and day-to-day school activities (functional impairment). The mean (SD) PHQ-9 score of the sample should be provided. The authors also report “mild” and “major” depressive symptoms based on PHQ-9; however, the score range of mild and major depressive symptoms category is not given.

The authors also report that substance use was assessed by a composite scale the asking the lifetime and the three months experience of using five substances: khat, alcohol, tobacco, shisha, and depressants, with an option of never (0), monthly (1), weekly (2) and daily (3). It appears that the scale does not evaluate noticeable problems (i.e., impairment) or distress that is an essential manifestation of substance use disorder; this assessment scale may show only recreational drinking or smoking. This makes it difficult to interpret the findings of this study whether it is referring recreational drinker or problematic alcohol users.

[Minor comments]

1) In Table 2, the prevalence of males having at least mild depressive symptoms is shown as 70.5% (n=235). According to my calculation it is 49.5% (n/N=235/475 = 0.4947), please check.

2) In Table 3, alcohol use in the last 3 months is shown as 173 (24.6%). The denominator should be all total substance users, 173/(28+25+173+33+24)=61.1%, please check.

3) English editing is needed.

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Reviewer #1: No

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Perceived learning difficulty associates with depressive symptoms and substance use among students of higher educational institutions in North Western Ethiopia: A cross sectional study

PONE-D-20-08001R1

Dear Dr. Bitew,

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.

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Kind regards,

Yutaka J. Matsuoka, MD, PhD

Academic Editor

PLOS ONE

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: All comments have been addressed

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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: Yes

**********

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: RE: PONE-D-20-08001 R1

The authors aimed to investigate the prevalence and risk factors of depressive symptoms and substance use among university students in North-Western Ethiopia. Points raised in the peer review were adequately addressed.

[Major comments]

The authors assert the importance of clinical depression and substance abuse; however, this cross-sectional study assesses the level of depressive symptoms and substance use that compromise with a flaw, limiting the clinical relevance which needs to be considered.

>>Authors state that they preferred the cross sectional survey as a first step just to know the prevalence of the problem. And have changed the substance use assessment scores into a count data to reduce limitation of the substance use scale, and focused only on the last three month data than the lifetime to focus on severity.

The authors report that the prevalence of mild levels of depressive symptoms to be about 30%, and that of major depressive symptoms to be about 40%. However, the mean (SD) PHQ-9 score of the sample is not given, which makes it ambiguous whether the sample has marked depression symptoms that may cause noticeable problems in relationships with others and day-to-day school activities (functional impairment). The mean (SD) PHQ-9 score of the sample should be provided. The authors also report “mild” and “major” depressive symptoms based on PHQ-9; however, the score range of mild and major depressive symptoms category is not given.

>>Authors have provided the mean and standard deviation of the PHQ-9 score in Table 1.

The authors also report that substance use was assessed by a composite scale the asking the lifetime and the three months experience of using five substances: khat, alcohol, tobacco, shisha, and depressants, with an option of never (0), monthly (1), weekly (2) and daily (3). It appears that the scale does not evaluate noticeable problems (i.e., impairment) or distress that is an essential manifestation of substance use disorder; this assessment scale may show only recreational drinking or smoking. This makes it difficult to interpret the findings of this study whether it is referring recreational drinker or problematic alcohol users.

>>Authors have changed the substance use assessment scores into a count data to reduce limitation of the substance use scale.

[Minor comments]

1) In Table 2, the prevalence of males having at least mild depressive symptoms is shown as 70.5% (n=235). According to my calculation it is 49.5% (n/N=235/475 = 0.4947), please check.

>>Table 2 has been revised.

2) In Table 3, alcohol use in the last 3 months is shown as 173 (24.6%). The denominator should be all total substance users, 173/(28+25+173+33+24)=61.1%, please check.

>>Table 3 has been revised.

**********

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