Prevalence of depression among students at Ethiopian universities and associated factors: A systematic review and meta-analysis

Tamrat Anbesaw; Yosef Zenebe; Mogessie Necho; Moges Gebresellassie; Tesfaye Segon; Fasikaw Kebede; Tilahun Bete

doi:10.1371/journal.pone.0288597

. 2023 Oct 12;18(10):e0288597. doi: 10.1371/journal.pone.0288597

Prevalence of depression among students at Ethiopian universities and associated factors: A systematic review and meta-analysis

Tamrat Anbesaw ^1,^*, Yosef Zenebe ¹, Mogessie Necho ¹, Moges Gebresellassie ², Tesfaye Segon ³, Fasikaw Kebede ⁴, Tilahun Bete ⁵

Editor: Wudneh Simegn⁶

PMCID: PMC10569578 PMID: 37824468

Abstract

Background

Depression is the most common cause of disability in the world, which affects 350 million people. University students struggle to cope with stressors that are typical of higher education institutions as well as anxiety related to education. Although evidence indicates that they have a high prevalence of depression, no reviews have been done to determine the prevalence of depression among students at Ethiopian universities comprehensively.

Methods

Without regard to time constraints, PubMed, Scopus, and EMBASE were investigated. A manual search for an article reference list was also conducted. The Meta XL software was used to extract relevant data, and the Stata-11 meta-prop package was used to analyze it. The Higgs I2 test was used to test for heterogeneity.

Results

A search of the electronic and manual systems resulted in 940 articles. Data were extracted from ten studies included in this review involving a total number of 5207 university students. The pooled prevalence of depression was 28.13% (95% CI: 22.67, 33.59). In the sub-group analysis, the average prevalence was higher in studies having a lower sample size (28.42%) than studies with a higher sample; 27.70%, and studies that utilized other (PHQ-9, HADS); 30.67% higher than studies that used BDI-II; 26.07%. Being female (pooled AOR = 5.56) (95% CI: 1.51, 9.61), being a first-year (pooled AOR = 4.78) (95% CI: 2.21, 7.36), chewing khat (pooled AOR = 2.83) (95% CI: 2.32, 3.33), alcohol use (pooled AOR = 3.12 (95% CI:3.12, 4.01) and family history of mental illness (pooled AOR = 2.57 (95% CI:2.00, 3.15) were factors significantly associated with depression.

Conclusion

This systematic review and meta-analysis revealed that more than one-fourth of students at Ethiopian universities had depression. More efforts need to be done to provide better mental healthcare to university students in Ethiopia.

Background

Depression is a common mental disorder which is characterized by sadness, loss of pleasure or interest, disturbance of sleep, psychomotor activity, difficulty to concentrate, decreased energy, guilty feeling, and recurring thought of death wish [1]. Depression has received increasing global attention because of its negative effects on interpersonal, social, and occupational functioning [2].

University students are a special group of people who are going through a key transition from adolescence to adulthood, which may be one of the most stressful times in their lives. Many students experience anxiety as they try to fit in, keep decent grades, prepare for the future, and be away from home [3]. As a reaction to this stress, some students become depressed. Also, depression contributes to lower academic performance, the chance of dropping out, suicidal behavior (ideation, plan, and attempt), and impact on peer and teacher interactions in addition to negative health consequences [4]. Without recognizing depression, students may cry all the time, skip classes, or isolate themselves [5]. Globally, the prevalence of depression among university students is estimated differently in different studies from 1.4% to 73.5% [6]. Depression has a great impact or impairment among university students that require attention for a better existence in public society. Various Studies across the world have reported different prevalence rates for depression. The prevalence of depression among university students in the United States 27.2% [3], Pakistan 42.66% [7], Iran 33% [5], and China 74% [8].

Different factors significantly associated with depression among university students such as being single [5], female gender [9–13], age [11, 14, 15], low academic achievement [11, 16], family problems [11, 17, 18], poor social support [19], family history of mental illness [17, 20], parental education [11, 17, 21], financial struggles [14, 16], the field of study [22], year of study [13, 14, 19], type of college [11], the satisfaction of major study [17], risky sexual behavior [23, 24], and substance use (alcohol, tobacco, and khat) [11, 16, 20, 23, 25–27]. Studies conducted in Ethiopia showed, being female [25, 26, 28], being a first-year student [25, 26, 28–30], monthly pocket money [31], having a mentally ill family member [30, 31], stressful life events [29], violent behavior [31, 32], being from the College of Social science and humanity [31], younger age [29], having a chronic medical illness [30], and current use of illicit substances [27].

Even though a wide range of studies showed depression as a significant public health problem in developing nations including Ethiopia, still there is no systematic review and meta-analysis conducted to assess the prevalence of depression among university students. Therefore, this systematic review and meta-analysis aimed to summarize the existing evidence on the prevalence of depression and the pooled odds ratio of the associated factors for depressive symptoms among university students and to formulate possible suggestions for future clinical practice and research community.

Materials and methods

Study designed

The PRISMA (preferred reporting items for systematic reviews and meta-analyses) standard was used to perform the frame of the whole review process [33].

Search strategy

An electronic and manual search of eligible articles was performed as part of a systematic review of the literature. Our search was conducted on October 10, 2022, using electronic libraries in Scopus, PubMed, and EMBASE, as well as manual exploration of the reference lists of articles. For searching articles on the prevalence of depression among university students using the PubMed database, we used the following search terms: “epidemiology” OR “prevalence” OR “magnitude” OR “incidence” AND “factor” OR “associated factor” OR “risk” OR “risk factor” OR “determinant”, “depressive symptoms”, “depressive disorder” OR “major depressive disorder” AND “University students AND Ethiopia”. Besides, the literature search in EMBASE and Scopus followed database-specific searching parameters. Furthermore, there was no specification for studies based on the study period in the reference list of included studies.

Inclusion and exclusion criteria

The researchers included original quantitative studies on the frequency and determinants of depression among university students. All observational studies were conducted by using different study-designed cross-sectional reports from June 2006 up to June 2021 were included. This systematic review and meta-analysis included publications with full-text papers and studies of depression that were published in peer-reviewed journals. Fortunately, studies published as review articles, qualitative studies, brief reports, letters to the editor, or editorial comments, working papers publications, published in a language other than English, research on non-human subjects, and studies with duplicate data from other studies were also excluded.

Outcome measurements

We have two objectives in this systematic review and meta-analysis study. These are to determine the pooled prevalence of depression among university students in Ethiopia and to estimate the pooled effects of associated factors with depression among university students in Ethiopia. The pooled prevalence of depression was calculated using STATA version 14.0. The pooled effect estimate of associated factors with depression was calculated. The odds ratio was prepared from the searched research reports using two by two tables.

Data extraction and appraisal of study quality

Two authors (TA, and YZ) checked study titles and abstracts for eligibility after deleting duplicates. The full texts were evaluated by the same reviewers if at least one of them thought an article was potentially eligible. Two authors (TA and YZ) extracted detailed information using a Microsoft Excel spreadsheet after the papers were scrutinized for their titles, abstracts, and entire texts. All studies approved by both reviewers were included and any differences were worked out through discussion to reach a consensus. Following the agreement, information about the principal investigator, years of publications, study period, study population, and sample size was retrieved from the identified articles. The identified articles were organized using EndNote X7.3.1. Each of the included studies’ risk of bias was assessed by six (TA, MN, MG, TS, FK, and TB) investigators. The Newcastle Ottawa quality evaluation checklist was used to assess the quality of the studies included in the final analysis [34]. Study participants and setting, research design, recruiting technique, response rate, sample representativeness, valid measuring convention, measurement reliability, and proper statistical analysis are all included in the quality evaluation checklist.

Data synthesis and analysis

We used a random-effect model to assess the overall prevalence of depression and the related variables for depression among university students, as well as their 95% CI’s [35]. Meta-XL version 5.3 [36] was employed to extract relevant data from included studies and the STATA11 Meta-prop package [37] was implemented to estimate the pooled prevalence of depression among university students and pooled odds ratio of the associated factors for depression. The Higgs I² statistic was also utilized to detect heterogeneity. Thus, percentages I² statistical values around 0% (I² 0), 25% (I² 25), 50% (I² 50), and 75% (I² 75) would mean absent, low, medium, and high heterogeneity, respectively [38]. Subgroup analysis and sensitivity analysis analyses were also used to investigate the source of heterogeneity among the studies included. To detect publication bias, researchers utilized the funnel plot test [39] and the eggers publication bias test.

Search results

Identification of studies

Our search with the pre-specified search strategies resulted in an overall of 935 articles. Besides, five articles were obtained from the reference list of included articles making the total number of retrieved articles to be 930 [25, 27, 29, 30, 32]. Of this, we removed 45 duplicated studies before further screening. In the next stage, we excluded 895 by title screening, being irrelevant to the main subject; and repetitive publications. Therefore the remaining 23 articles had been completely inspected for eligibility to be included in the current systematic review and meta-analysis study; nevertheless, only 10 articles were tailored in the final meta-analysis since the rest 13 articles were also excluded due to various reasons; 7 articles were poor methodological assessment, 4 articles were reviewed studies, and 2 articles were published other than the English language) (Fig 1).

Characteristics of included studies

We included ten studies that assessed the prevalence and associated factors of depression among university students [25–32, 40, 41]. These studies included a total of 5207 university students. Five [27, 30, 31, 40, 41], two [25, 28] two [26, 32], and one [29] of the included studies used the BDI-II, PHQ-9, CESD’s questionnaire, and HADS, respectively, to measure depression in university students. Regarding the study’s design, all studies were institutional-based cross-sectional [25–32, 40, 41]. Also, eight of the studies employed a simple random sampling technique during data collection, and two studies used systematic random sampling [27, 29]. All of the studies reported response rates [25–32, 40, 41] (Table 1).

Table 1. Characteristics of studies on depression among university students are incorporated in this meta-analysis according to author’s first name, year of publication, setting of the study, design, sample size, assessment tools, study population, sampling methods, age, and magnitude of depression, response rate.

Author, year of publication	Place	Study design	Sample size	Instrument and cutoff value	Study Population	Sampling Technique	Age	Overall prevalence of depression (%)	Response Rate
Birhanu et al. 2016 [25]	Ambo, Ethiopia	CS	410	CES-D >22	University students	Simple random	M & F 17–23 years	32.2(n = 132)	96.9%.
Tamene et al. 2021 [26]	Debre birhan, Ethiopia	CS	369	PHQ-9 ≥10	University students	Simple random	M & F 18 and 33	17.1(n = 63)	100%
Ahmed et al. 2020 [31]	Jimma, Ethiopia	CS	556	BDI-II> 14	University students	Simple random	M & F 18 to 35 years	28.2(n = 157)	94.9%
Terasaki et al. 2009 [32]	Hawassa, Ethiopia	CS	1,176	PHQ-9 >10.	University students	Simple random.	M & F > 18 years	23.6(n = 277)	100%
Kebede et al. 2019 [29]	Addis Abba, Ethiopia	CS	273	HADS>8	University students	Systematic sampling	M & F 18–21 years	51.30(140)	98.5%
Muhammed et al. 2019 [30]	Wollo, Ethiopia	CS	334	BDI-II 14–63	University students	Simple random	M & F 18 to 35 years	35.3(118)	100%
Dagnew et al. 2020 [41]	Gondar, Ethiopia	CS	383	BDI-II = 21–63	University students	Simple random	M & F 18–34	34.73(n = 133)	97.7%
Worku et al. 2020 [40]	Arsi, Ethiopia	CS	384	BDI-II >14	University students	Simple random	M & F 18–30 years	4.4(n = 17)	100%
Berhanu et al. 2020 [28]	Addis Ababa, Ethiopia	CS	300	CES-D >16	University students	Simple random	M & F 17–28 years	27.7(n = 83)	95.5%
Teshome et al. 2020 [27]	Haramaya, Ethiopia	CS	1022	BDI-II > 13	University students	Systematic random	M & F 20–24	26.8(274)	98.3%

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Key: M = Male, F = Female

Quality of included studies

The quality of ten studies [25–32, 40, 41] was assessed with the modified Newcastle Ottawa quality assessment scale. This scale divides the total quality score into 3 ranges; a score of 7 to 10 as very good/good, a score of 5 to 6 as having satisfactory quality, and a quality score less than 5 as unsatisfactory [42]. All studies had scored good quality (Table 2).

Table 2. Quality assessment result of the studies included in this meta-analysis.

Study ID	Representation	Sampling	Random Selection	Non-response Bias	Data Collection	Case Definition	Reliability and Validity	Method of Data Collection	Prevalence Period	Numerator and Denominator	Summary
Birhanu et al. 2016 [25]	1	1	1	1	1	1	1	1	1	1	10
Tamene et al. 2021 [26]	0	1	1	0	1	1	1	1	1	1	8
Ahmed et al. 2020 [31]	1	1	1	1	1	1	1	1	1	1	10
Terasaki et al. 2009 [32]	1	1	1	1	1	1	1	1	1	1	10
Kebede et al. 2019 [29]	0	1	1	1	0	0	1	1	1	1	7
Muhammed et al. 2019 [30]	0	1	1	1	1	0	1	1	0	1	7
Dagnew et al. 2020 [41]	0	1	1	1	1	1	1	1	1	1	9
Worku et al. 2020 [40]	0	1	1	1	1	1	1	1	1	1	9
Berhanu et al. 2020 [28]	0	1	1	1	1	1	1	1	1	1	9
Teshome et al. 2020 [27]	1	1	1	1	1	1	1	1	1	1	10

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The pooled prevalence of depression among university students

The pooled prevalence of depression among students at Ethiopian universities was found to be 28.13% (95% CI: 22.67, 33.59); (I² = 100%, p-value < 0.001) (Fig 2).

Subgroup analysis of the prevalence of depression among university students

Subgroup analysis of the prevalence of depression among university students by the sample size

Since the average prevalence of depression was significantly influenced by the difference between the included studies, it was mandatory to conduct a subgroup analysis. Therefore, we used a sample size of below 400 [25, 27, 31, 32] provided a higher prevalence of depression; 28.42% than those who had a sample size above 400 [25, 26, 29, 30, 40, 41]; 27.70% (Fig 3).

Subgroup analysis of the prevalence of depression among university students by the tools

The measurement tools for depression to perform subgroup analysis. The subgroup analysis by assessment instrument yields that measurement with other (PHQ-9, HADS) [26, 29, 32] provided relatively higher result, 30.67% (95% CI: 12.06, 49.27) with (I2 = 100%, p < 0.001) than the result with CEDS’s [25, 27], which was 29.50% (95% CI:24.21, 34.79) (I2 = 99.9%, p < 0.001) and BDI-II [25, 30, 31, 40, 41], which was 26.07(19.42,32.72) (I2 = 100%) (Fig 4).

Sensitivity analysis

The sensitivity analysis was performed to identify whether one or more of the ten studies had out-weighted the average prevalence of depression among university students. However, the findings show that all values are within the estimated 95% confidence interval, indicating that the absence of one study had no significant difference in the prevalence of this meta-analysis (Fig 5).

Publication bias

A scatter plot of the logit event rate of depression on the X-axis and its standard error on the Y-axis was done, which showed that there was a publication bias since the graph was slightly asymmetrical. However, the Eggers publication bias test revealed that there was no significant publication bias (B = 9.19, SE = 94.5, and P-value = 0.92) (Fig 6).

Associated factors for depression among students at Ethiopian universities

As stated previously, ten studies [25–32, 40, 41] reported one or more factors related to the development of depression among university students. Our narrative synthesis revealed that being female [25, 26, 28], being a first-year student [25, 27, 30], current use of khat [25, 30], alcohol use [26, 27], and having a family history of mental illness [30, 31] were among the most commonly reported factors contributing to the development of depression among university students (Table 3).

Table 3. Characteristics of associated factors for depression among university students in Ethiopia by their odds ratio, confidence interval, association strength, author, and year of publication.

Author, year of publication	Factor category	Associated factors	AOR	95% CI	Strength of association
Birhanu et al. 2016	Socio-demographic factors	Being female	4.02	1.22,4.03	Strong
	Socio-demographic factors	Being first-year student	3.00	3.02,7.25	Strong
	Substance-related	Current use of Khat	3.05	2.05,6.02	Strong
Tamene et al. 2021	Socio-demographic factors	Female	9.28	3.47–24.81	Strong
		Academic year	0.236	0.059–0.936	Weak
		Smoking	26.3	9.33–74.1	Strong
		Alcohol use	2.62	0.95–7.21	Strong
Ahmed et al. 2020	Socio-demographic factors	Having monthly pocket money between 500–999 ETB	0.450	0.204–0.995	Weak
		Being from the College of Social Science and Humanity	2.582	1.332–5.008	Strong
		Promoted academic performance	2.912	1.063–7.975	Strong
	Clinical factors	Having a mentally ill family member	2.307	1.055–5.049	Strong
	Risky sexual behavior	Having sex after drinking	3.722	1.818–7.619	Strong
	Risky sexual behavior	Being hit by sexual partner	3.132	1.561–6.283	Strong
	Negative life event	Having childhood emotional abuse	2.167	1.169–4.017	Strong
Terasaki et al. 2009	Negative life event	Moderate outward anger	1.97	1.33–2.93	Weak
		High outward anger	3.23	2.14–4.88	Strong
		Violent behavior	1.82	1.37–2.40	Weak
Kebede et al. 2019	Socio-demographic factors	Age interval 18–21 years	2.42	1.64, 9.22	Strong
		1^st-year educational level	1.63	1.43, 6.26	Weak
		2^nd-year educational level,	1.39	1.17, 5.18	Weak
	Negative life event	Stressful life events	1.61	1.14, 2.76	Weak
Muhammed et al. 2019	Socio-demographic factors	Being male	1.69	1.96–2.98	Weak
	Socio-demographic factors	Study year (first year)	4.33	1.40–13.39	Strong
	Clinical factors	Having a chronic medical illness	2.07	1.19, 3.57	Strong
	Clinical factors	Family history of mental illness	2.89	1.37–6.16	Strong
	Substance use	Khat chewing,	2.53	1.16–5.51	Strong
Dagnew et al. 2020	Socio-demographic factors	Students who came from a rural family	1.67	1.02–2.72	Weak
	Socio-demographic factors	Those studying Health sciences	2.65	1.34–5.26	Strong
	Clinical factors	Experienced tooth grinding,	2.79	1.36–5.74	Strong
		Night sleep disturbances	1.95	1.17–3.25	Weak
		Who reported daytime sleepiness	1.93	1.16–3.20	Weak
		Stress	4.20	1.90–9.26	Strong
Worku et al. 2020	Psychosocial	Thinking about a future career prospect	8.415	1.039, 68.14	Strong
Berhanu et al. 2020	Socio-demographic factors	Female students	3.36	1.88, 6.01	Strong
Teshome et al. 2020	Socio-demographic factors	Being divorced/widowed	5.91	1.31, 26.72	Strong
		Being a first-year student	6.99	2.31, 21.15	Strong
		Being second-year student	6.25	2.05, 19.07	Strong
		Being a third-year student	3.85	1.26, 11.78	Strong
	Substance-related	Current drinking alcohol	2.53	1.72,3.72	Strong
		Current smoking cigarettes	1.71	1.02, 2.86	Weak
		Current use of illicit substances	2.20	1.26, 3.85	Strong

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The pooled odds ratio of being female among the above-mentioned studies was 5.56 (95% CI: 1.51, 9.61). This implied that female students were 5.56 times at higher risk of developing depression than male students. The pooled odds ratio for being a first-year student for the three studies reported above was found to be 4.78 (95% CI: 2.21, 7.36). Students who were first-year students were 4.78 times more likely to be depressed than senior students. History of chewing khat was also an associated factor for the development of depression with a pooled estimate odds ratio of 2.83 (95% CI: 2.32, 3.33). Besides, alcohol use was also found to have a significant association with the development of depression with an estimated pooled odds ratio of 3.12 (95% CI:3.12, 4.01). Participants who had a family history of mental illness was found to have a significant association with the development of depression with an estimated pooled odds ratio of 2.57 (95% CI:2.00, 3.15) (Table 4).

Table 4. A pooled estimate of the associated factors for depression among students in Ethiopian universities.

Associated Factors	Risk Groups	Pooled Effect Size & 95% CI	I2	Studies Pooled
Being female	Students who were females	5.56 (1.51,9.61)	99.5%	[25, 26, 28]
Being a first-year student	Students who were a first-year student	4.78 (2.21,7.36)	99.1%	[25, 27, 30]
Current use of khat	Those students who are using Khat	2.83(2.32,3.33)	24.6%	[25, 30]
Alcohol use	Those students who are using alcohol	3.12(2.23,4.01)	83.7%	[26, 27]
Family history of mental illness	Students who had a family history of mental illness	2.57(2.00,3.15)	46.4%	[30, 31]

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Discussion

The pooled estimated prevalence of this systematic review and meta-analysis was 28.13% with a 95% CI (95% CI: 22.67, 33.59). This result was in line with another study conducted in China (32.74%) which analyzed 15 studies and 35,160 students [8]. It was also consistent with the result of a systematic review and meta-analysis study from Iranian university students which assessed 35 studies with a sample size of 9743 and 33% of them were found to have depression [5]. It was consistent with the study of Chinese university students which assessed 113 studies, and 28.4% of them were found to have depression [43]. Another study that involved 76,608 and 37 studies from low and middle-income countries [44] reported 24.4% of students as having depression, which was also supportive of the current finding. Our meta-analysis is much higher than in investigating the pooled prevalence of depression among the general population in Ethiopia (9.1% to 11%) [45, 46]. The findings revealed that several distinct characteristics of university students, such as increased social interactions and shifting residential and financial situations, may raise the risk of depression [47].

On the contrary, the average prevalence of depression in the present review was lower when compared with Asian university students on 8916 subjects, and in 27 articles a pooled prevalence of depression was 34.0% [48]. It was also lower than the systematic review and meta-analysis conducted on depression in Pakistani among 7652 university students and 26 studies in which the mean prevalence of depression was 42.66% (95% CI: 34.8–50.9%) [7]. The reason for the discrepancy might be because these investigations used different evaluation standards and measurement instruments, there could have been differences in prevalence rates.

The pooled prevalence of depression among university students in studies using a sample size below 400 study subjects (28.42%) [25, 27, 31, 32] was higher than the pooled prevalence of depression in university students that used a sample size of greater than 400 (27.07%) [25, 26, 29, 30, 40, 41]. The reason could be a smaller sample size increases the probability of a standard error thus providing a less precise and reliable result with weak power. Likewise, the present study revealed that pooled prevalence of depression was higher in studies as measured with other (PHQ-9, HADS) [26, 29, 32]; 30.67% (95% CI: 12.06, 49.27) than the result with CEDS’s [25, 27] (29.50% (95% CI:24.21, 34.79) and BDI-II [25, 30, 31, 40, 41], which was 26.07(19.42,32.72). This could be because studies that utilized delineated (PHQ-9, HADS) a lower cut-off point (PHQ-9 score ≥ 10 and HADS score > 8), which might result in an overestimation of the prevalence of depression.

Regarding the associated factors of depression, ten studies [25–32, 40, 41] had reported different factors and being female [25, 26, 28], being a first-year student [25, 27, 30], current use of khat [25, 30], alcohol use [26, 27], and having a family history of mental illness [30, 31] were among the most commonly reported factors. The pooled odds ratio of being female among the above-mentioned studies was 5.56, which implies, that those female students were 5.56 times at higher risk of developing depression than males. A meta-analysis study in China showed a similar conclusion supporting this [49]. Female students are more likely to be depressed [26], and women are more likely than men to suffer from depression. Women are more likely than males to suffer from moderate to severe depression [17]. The disparity could be related to social and cultural factors. Biological conditions are another factor that contributes to the disparity [47].

Besides, the pooled odds ratio of first-year students for the three studies reported above was found to be 4.78. This showed that those who were first-year students were 4.78 times more likely to be depressed than senior students. This might be caused by a lack of social interaction, an unfamiliar exam schedule, a lesser grade than expected, a lack of vacation or a break, a language barrier, or any combination of these factors [50].

Furthermore, the pooled odds ratio of chewing khat and alcohol usage was 2.83 and 3.12 respectively. Even if the cause and effect are not obvious in this study, this result could be related to either the fact that depressed students are more prone to substance use to relieve themselves from the melancholy mood or because maladaptive drug use can modify their mood to the point of depression [1]. Participants who use drugs or alcohol may experience feelings of isolation, despair, and hopelessness that are frequently linked to depression [51].

Finally, students who had a family history of mental illness were 2.57 times more likely to have depression as compared to students who had no family history of mental illness. This association might present as a result of genetic factors, the burden of stigma, and there are many various sorts of financial constraints on family members, and caring for the patient and the children may also put them under stress and worry about their parent’s health, which may raise the likelihood that they may experience depression [1]. There are many various sorts of financial constraints on family members, and caring for the patient and the children may also put them under stress and worry about their parent’s health, which may raise the likelihood that they may experience depression [52].

Strengths and limitations

To our knowledge, this is the first meta-analysis of the prevalence of depression among students at Ethiopian universities. However, one of the limitations of this meta-analysis study is that the choice of cut-point by researchers and assessment tools varies depending on where the study was conducted. Second, because so many studies were observational and their subjects were not chosen randomly, it was challenging for us to assess how well they were conducted because so many of them lacked trustworthy information on key factors or appropriate information on the persons they were examining. Confounding and selection bias, therefore, appears inevitable. Thirdly, limited research on mental health in Ethiopia given it is a country that has few psychiatrists nowadays and that stigma may play a role in the responses given by students. Finally, studies other than cross-sectional.

Implications of this study for clinical practice, researchers, and policymakers

First, this review showed that clinical professionals (clinical psychologists, psychiatrists, sociologists, lecturers, and student counselors) who work in student clinics should be aware that depression is a widespread issue among university students and be prepared to provide patients with management or treatment. Second, the review’s findings that the average estimated prevalence of depression among university students is higher than the average estimated prevalence of depression in the general population prompt the question of why this is so and what causes it to be so. Finally, the findings let policy-makers and program planners know that depression is a serious public health issue among university students. This lessens the need for a comprehensive strategy for treating depression among university students.

Conclusion

This review and meta-analysis study found that the pooled prevalence of depression among students is 28.13%. The findings suggest a high prevalence of depression among university students. Factors being female, being a first-year, chewing khat, alcohol use and family history of mental illness were factors significantly associated with depression.

Supporting information

S1 Checklist. PRISMA-P 2015 checklist.

(DOCX)

Click here for additional data file.^{(81.5KB, docx)}

S1 Data

(XLSX)

Click here for additional data file.^{(11.8KB, xlsx)}

Acknowledgments

We acknowledge the authors of the included studies for their original contribution.

List of abbreviations

AOR: Adjusted Odds Ratio
BDI-I: Beck’s Depression Inventory-I
CES-D: Center for Epidemiologic Studies Depression scale
CI: Confidence Interval
CS: Cross-Sectional
ETB: Ethiopian Birr
HADS: Hospital Anxiety and Depression Scale
OR: Odds Ratio
PHQ-9: Patient Health Questionnaire-9
PRISMA-P: Preferred Reporting Items for Systematic Reviews and Meta-analysis

Data Availability

All relevant data from this study will be made available upon study completion.

Funding Statement

The authors received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0288597.r001

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21 Feb 2023

PONE-D-22-34689Prevalence and associated factors of depressive symptoms among Ethiopian University students: a systematic review and meta-analysis.PLOS ONE

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Reviewer #1: Title:

" Prevalence and associated factors of depressive symptoms among Ethiopian University students: a systematic review and meta-analysis"

1. Thank you for your invitation to review this systematic review and meta-analysis with topic Prevalence and associated factors of depressive symptoms in Ethiopia: A systematic review and meta-analysis., but my concern there is gross errors on the documents starting from the article type says protocol but is already done article.

2. On abstract section line “26” it says depression which affects 350 million people.no need of magnitude of number here rather talk about the problem and severity. It is better to focus on university students rather than general population.

3. Method line 32, Only three data base is not enough for systematic review and meta-analysis. At list five database is recommended to get adequate number of articles. how do you get access of EMBASE in Ethiopia. Even Addis Ababa university has no access to it, I need strong evidence how they get access? Unless they lay no one had an access in Ethiopia for that data base.

4. What is their search strategy that they follow? it is a mandatory to have search strategy on systematic review and meta-analysis, I could not get nothing on their search strategy.it is not based on PICOT(PICO)… it needs more clarification?

5. Method part of abstract lacks pertinent information about the analysis, Prisma guideline and how they declared the significancy.

6. How many articles on each data base that they got from PubMed, PubMed, Scopus?

7. Conclusion part line,48 says More efforts need to be done to provide better mental healthcare to university students in Ethiopia. It is not your objective conclusion should be based on your finding talk on associated factors that have effect for development of depressive symptoms.

8. Search strategy for each data base is different from one another .so is it the search strategy listed for three of databases? the listed search strategy from line 108 to 117 is not used from PubMed. PubMed is searched with the topic of the review “Prevalence and associated factors of depressive symptoms among Ethiopian University students” how about others like Scopus and Embase?

9. Did this article have registered in any protocol, then what about protocol registration to avoid duplication of efforts?

10. Line 120 inclusion and exclusion criteria it says English language full-text papers were included. What about abstracts that have adequate information on prevalence and predictors.

11. What does this mean “research on non-human subjects”? you are working on university students, or do you have previous knowledge that talks about depression on non-human animals.

12. How do you remove duplicates? on line 126,

13. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) standard was used to perform the literature search. It is a procedure for screening and excluding articles /flow diagram that shows presentation. How it could be used for literature search?

14. Data extraction and appraisal of study quality should be written again it is not clear who should do the interrater disagreement between (TA, and YZ)?

15. Why they used random effect model for Data synthesis and analysis? why not fixed effect?

16. I do not think any article available with The I2 statistical values of zero please see it again.

17. Table 1 heading is too long and difficult to understand better to make it shot and readable.

18. Overall prevalence of depressive symptoms (%) should be recommend to put with confidence interval.

19. On figure -3 after subgroup analysis their high heterogeneity. what do you recommended or expected to be done. I did not see and meta regression analysis.

20. On line 241 Associated factors for depressive symptoms in Ethiopian university … what?

21. No forest plot for the pooled effect estimate/odd ration of factors that have an association on depressive symptoms among university students.

22.” MA” what is this mean?

Reviewer #2: First of all, I would like to thank the journal’s editor(s) for believing in me to review this work. I would also like to thank the authors for conducting such a review. However, the work has several minor flaws, which are provided below.

Title and abstract

First and foremost, is your work a “protocol” or a “full review”?

As can be easily inferred from the title, the authors tried to review the prevalence of the symptoms of depression. However, they did not show which symptom of depression is the most prevalent, and so on. Unless the title should be rephrased as “Prevalence of depression among students at Ethiopian universities and associated factors: a systematic review and meta-analysis.”

Avoid saying “Ethiopian university students,” which implies that only students with Ethiopian citizenship. It might be more acceptable to say "students at Ethiopian universities." Because, grammatically, it makes sense, but its meaning deviates from the aim. Or if the authors' intention was to address only Ethiopian students, they would be right.

“The pooled prevalence of depressive symptoms was 28.13% (95% CI: 22.67, 33.59).” But where are the symptoms? In fact, symptoms, which are only expressed by the person with the condition of interest, are indicators of a disorder. However, the symptoms should be listed in order of their prevalence, as per the aim of the review. We know that depression has various symptoms. This pooled data only showed the prevalence of depression, whether major or minor. The conclusion is ambiguous.

“…one-fourth of students in Ethipisn University…” But the title is different; it is about “Ethiopian university students," not “students in Ethiopian universities.” It is also good to revise grammar issues throughout the manuscript. For instance, because the study is a review covering various universities, it is better to write "universities" than "university." See also the word "Ethipisn" in this phrase.

Background

Page 3 and 4, lines 70-90: This should be discussed in comparing with your finding under the discussion section. In the introduction section, it is better to explain and discuss the extent to which depression impacts the life and activities of students in universities.

Page 3, line 73: “…42.66 of students…” What did you mean?

Page 3, line 82: “The most consistently significantly associated factors among university students…” What did you mean? Please revise grammar issues throughout the manuscript.

Materials and methods

Page 5, lines 110-112: “Our search was conducted on the 10th of the October 2022 using electronic libraries in Scopus, PubMed, and EMBASE and manual exploration of the reference list of articles were the backbones of the current meta-analysis.” This is an ambiguous long sentence and shall be rephrased as “Our search was conducted on October 10, 2022, using electronic libraries in Scopus, PubMed, and EMBASE, as well as manual exploration of the reference lists of articles.”

Page 5, lines 122-124: “The study was cross-sectional, English-language full-text papers, the subject of study should be any type of university student, and studies should be done in Ethiopia.” This sentence needs grammatical revision.

Page, lines 124-127: “Studies published as review articles, qualitative studies, brief reports, letters to the editor, or editorial comments, working papers publications, published in a language other than English, research on non-human subjects, and studies with duplicate data from other studies were also excluded.” Why have you excluded qualitative inquiries while they are important in providing in-depth exploration of the individual students' experiences that could make your systematic review strong evidence to assure the prevalence of depression among your population of interest? Furthermore, why did you use research on non-human subjects as an exclusion criterion when your population of interest was students, i.e., human beings? This is totally out of the scope of your review, so it does not sound like it used animals as an exclusion criterion. The exclusion should be decided within the context of the research goal rather than on the basis of completely separate issues. By the way, could you list those listed as excluded article types?

Page 5, lines 127-128: “The PRISMA (preferred reporting items for systematic reviews and meta-analyses) standard was used to perform the literature search (36).” This is not clear. How did you use the PRISMA checklist for the literature search? As far as I know, they are used to frame the whole review process. The other major issue here is that the PRISMA version you cited is the 2009 version, but you used the PRISMA 2015 version in the supporting file. Why has the discrepancy taken place?

Page 5, lines 130-131: “Two authors (TA, and YZ) checked study titles and abstracts for eligibility after deleting duplicates.” How were the duplicates removed? For example, what automated tool(s) were used to remove the duplicates?

Page 5, lines 131-132: “The full texts were evaluated by the same reviewers if at least one of them thought an article was potentially eligible.” This is also not clear. Why did two authors participate or take part if one of them could decide without consensus?

Page 6, lines 148-149: What is the need to measure the Cochran Q-statistics if I2-indices are employed? Additionally, do you think that these statistics can provide information on the specific factor causing heterogeneity? You said that if I2 is zero, it shows the absence of heterogeneity. Did you think that you were correct or right? If you think so, this is absolutely unacceptable in statistics. Even the included studies have heterogeneity within themselves.

Page 6, lines 150-151: “Subgroup analysis and sensitivity analysis analyses were also used to investigate the source of heterogeneity among the studies included.” This sentence should be rewritten as "Subgroup and sensitivity analyses were also used to investigate the source of heterogeneity among the studies included."

Page 6, line 152: When do you think publication bias occurs?

Results

Page 7, line 166: “…5 articles were obtained from the reference list of included articles…” Could you please cite those articles? It is also recommended to spell out numbers with one digit rather than write them with their digit values.

Page 7, line 169: “…repetitive publications…” How many of them were published repeatedly? Please cite those resources.

Page 7, line 171: “…10 articles were tailored in the final meta-analysis…” How many articles were first included in the qualitative synthesis (the systematic review) before considering eligibility for the quantitative meta-analysis?

Page 7, lines 172-173: “…7 articles were poor methodological assessment, 4 articles were reviewed studies, and 2 articles were published other than the English language).” Please cite them.

Page 8, Table 1: "Tamene et al., 2021" is listed under the heading of the first column in an inappropriate place.

"Seid et al. 2019" is listed as reference number 33. However, even though the source is correct, the reference number 33 is listed differently as "Muhammed et al."

"Berhanu et al. 2020," which is listed in tables 1 and 2 and figures 2–5, is differently cited in reference list number 31.

"Teshome et al. 2019," which is listed as reference 30, is not consistent with its citation; for instance, the year is 2020 in the reference list.

Page 9, lines 202-204: “The pooled prevalence of depressive symptoms among university students from ten studies (28-35, 43, 44) included studies conducted in Ethiopia was 28.13% (95% CI: 22.67, 33.59) with significant heterogeneity among the studies (I2 = 100%, p-value < 0.001) (Fig 2).” It needs grammar revision.

Page 10, lines 230-231: “However, the result showed that there was no single influential study since the 95% CI interval result was obtained when each of the ten studies was excluded at a time (Fig 5).” It is not clear.

Page 12, lines 161-162: Please avoid the use of words such as "furthermore" and "also” simultaneously.

Discussion

Please do not repeat strategies, and procedures under this section, which you mentioned in the method’s section. Simply discuss your findings by comparing them to other relevant resources. For instance, the explanation from lines 274–282 is unnecessary.

Page 13, lines 268-272: This shall be discussed under the discussion's sub-title, "practical implications."

Page 14, lines 288-292: Is it appropriate to use "additionally" with "also" or "furthermore" with "also" simultaneously?

Page 14, line 294: “The findings revealed that several distinct characteristics…” Which findings? Yours or the comparators you mentioned? It is not clear.

Page 15, line 319: “…were were…” Please delete one.

Page 16, lines 344-347: Where did you get this? It needs to be cited. Or you should not be sure if it is your own justification.

Strengths and limitations

Page 16, line 349: Write "MA" in its expanded form, or you can abbreviate it from the beginning.

Can including old references be a strength of your review while our world is being drastically changed by technology, which is also a major reason for students to be frustrated with their education, which could result in anxiety and depression during exam time, and so on?

Please include other limitations such as pooling data despite high heterogeneity, studies other than cross-sectional, studies published in other languages, etc. Because all of these are the limitations of this review.

Implications of this study for clinical practice, researchers, and policymakers

Why did you skip the role of psychologists, psychiatrists, sociologists, lecturers, student counselors, etc. working in universities, as they are not stakeholders to take part in solving the issue?

Conclusion

Please be focused on the prevalence and the associated factors. Avoid making recommendations in this section, as they have already been mentioned under the implications section.

Declarations

Is the review protocol not registered in a registry data base, such as PROSPERO? If not, how did you know your review is the first of its kind in Ethiopia?

References

There are several major flaws within the organization of the reference lists. So, you should revise cautiously.

Reviewer #3: The authors should work more on methodology, errors and coherence of sentences.

It seems as you followed PRISMA checklist for reporting this systematic review and meta-analysis but you did not followed it correctly. Please follow The PRISIMA checklist while reporting and the whole method should be reorganized based on PRISMA checklist recommendation.

**********

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Reviewer #1: No

Reviewer #2: Yes: Ewunetie Mekashaw Bayked

Reviewer #3: No

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PLoS One. 2023 Oct 12;18(10):e0288597. doi: 10.1371/journal.pone.0288597.r002

Author response to Decision Letter 0

10 May 2023

Comments to the authors

PLOS ONE

PONE-D-22-34689

Article Type: Study Protocol

Prevalence and associated factors of depressive symptoms among Ethiopian University students: a systematic review and meta-analysis

First of all, I would like to thank the journal’s editor(s) for believing in me to review this work. I would also like to thank the authors for conducting such a review. However, the work has several minor flaws, which are provided below.

#Response: Thank you for your positive feedback, it gives the strength do more.

Title and abstract

First and foremost, is your work a “protocol” or a “full review”?

#Response: Thank you, dear reviewer. We will update the system which a full review.

#Response: Thank you dear reviewer for your positive feedback. We accepted and modified it.

#Response: Again we appreciate your comment. Amended.

#Response: Thank you for your comment. We modified the title based on your recommendation. We appreciate your comments. See the revised manuscript.

#Response: We completely accepted and action has been taken. Thank you so much.

Background

#Response: Thank you we rewrite again. We minimized it.

Page 3, line 73: “…42.66 of students…” What did you mean?

#Response: Typing error. We want to describe the percentage of depression which is 42.66 %.

Page 3, line 82: “The most consistently significantly associated factors among university students…” What did you mean? Please revise grammar issues throughout the manuscript.

#Response: We amended it as “Different factors significantly associated with depression among university students such as….”

Materials and methods

#Response: Really dear reviewer we appreciate you help to amend our manuscript. We revised as recommended.

#Response: We revised it.

#Response: Thank you for your constructive comment. This was our predetermined exclusion criteria. We have not excluded qualitative studies during the actual analysis. We that some articles conducted on human subject will be obtained during the search process. But after searching process we have nor get such articles. We removed “research on non-human subjects”.

#Response: We thank your critical point of view. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) standard was used to perform the systematic reviews and meta-analyses process. But during the literature search process. We cite the updated reference (PRISMA ). We accepted your very supportive comment. Really we are surprising by your comment.

#Response: Using the endnote reference manager duplicated articles were excluded. Again we revised the sentence. See document.

#Response: We accepted your constructive comments. See the main document.

#Response: We accepted your comment. The Higgs I2 statistic was also utilized to detect heterogeneity.

#Response: We accepted it.

Page 6, line 152: When do you think publication bias occurs?

#Response: Publication bias occurs when the publication of research results depends not just on the quality of the research but also on the hypothesis tested, and the significance and direction of effects detected. During testing meta-bias test, the P- value is < 0.05.

Results

#Response: We Accepted and cited it.

Page 7, line 169: “…repetitive publications…” How many of them were published repeatedly? Please cite those resources.

#Response: This is a very critical view and we accept the comments. This editorial problem. repetitive publications is replacedby duplicated articles. There was too many duplication. In the future we will consider your comment.

#Response: Full-text articles excluded with reasons (n = 13, 7 poor methodological assessment, and 4 were (n = 13, 7 poor methodological assessment, and 4 were reviewed studies, and 2 were published other than English language)

Response: We amended it as per recommendation.

Page 7, lines 172-173: “…7 articles were poor methodological assessment, 4 articles were reviewed studies, and 2 articles were published other than the English language).” Please cite them.

#Response: Thank you, dear reviewer. We accepted the comment.

Page 8, Table 1: "Tamene et al., 2021" is listed under the heading of the first column in an inappropriate place.

#Response: Thank you for your critical view. We removed it.

"Seid et al. 2019" is listed as reference number 33. However, even though the source is correct, the reference number 33 is listed differently as "Muhammed et al."

#Response: Revised.

"Berhanu et al. 2020," which is listed in tables 1 and 2 and figures 2–5, is differently cited in reference list number 31.

#Response: We have seen it and are now correctly cited.

"Teshome et al. 2019," which is listed as reference 30, is not consistent with its citation; for instance, the year is 2020 in the reference list.

#Response: We accepted and revised accordingly.

#Response: We revised it accordingly. Thank you dear reviewer. Please see the main document.

#Response: We write it as “The findings show that all values are within the estimated 95% confidence interval, indicating that the absence of one study had no significant difference on the prevalence of this meta-analysis.”

Page 12, lines 161-162: Please avoid the use of words such as "furthermore" and "also” simultaneously.

#Response: We removed it.

Discussion

#Response: Removed. Thank you for your comment!

Page 13, lines 268-272: This shall be discussed under the discussion's sub-title, "practical implications."

#Response: We accepted.

Page 14, lines 288-292: Is it appropriate to use "additionally" with "also" or "furthermore" with "also" simultaneously?

#Response: Again we appreciated for your critical view.

Page 14, line 294: “The findings revealed that several distinct characteristics…” Which findings? Yours or the comparators you mentioned? It is not clear.

#Response: Dear reviewer we included it for comparison. Being a first-year, substance use like chewing khat, family history of mental illness and other several factors can contribute for the risk of depression compared to general population. Several characteristics of university students, such as increased social interactions and shifting residential and financial situations, may raise the risk of depression.

Page 15, line 319: “…were were…” Please delete one.

#Response: Removed

Page 16, lines 344-347: Where did you get this? It needs to be cited. Or you should not be sure if it is your own justification.

#Response: We cited it.

Strengths and limitations

Page 16, line 349: Write "MA" in its expanded form, or you can abbreviate it from the beginning.

#Response: Based on your valuable comment. We avoided from the strength of the study. We revised it. Our assumption is not to exclude findings from the study.

#Response: We included in the review.

Implications of this study for clinical practice, researchers, and policymakers

Why did you skip the role of psychologists, psychiatrists, sociologists, lecturers, student counselors, etc. working in universities, as they are not stakeholders to take part in solving the issue?

#Response: Thank you! the role for treating of disorder is clinical professionals that include clinical psychologists and psychiatrists and we rewrite it comprehensively as per showing the direction. We incorporated it.

Conclusion

Please be focused on the prevalence and the associated factors. Avoid making recommendations in this section, as they have already been mentioned under the implications section.

Response: We amended as per recommendation.

Declarations

Is the review protocol not registered in a registry data base, such as PROSPERO? If not, how did you know your review is the first of its kind in Ethiopia?

Response: We have conducted an extensive search strategy with all search data bases. Not obtained systematic review and meta-analysis were conducted among students.

References

There are several major flaws within the organization of the reference lists. So, you should revise cautiously.

Response: We revised the thoroughly. Thank you for your all positive comments.

Reviewer 2

An important topic was raised in this review and meta-analysis even though meta-analysis in prevalence studies are hard to interpret and generalize because of considerable heterogeneity. I presented here my comments which helped the authors to strengthen their manuscript.

Response: Thank you for your positive feedback, it gives the strength to do more.

Abstract

Result: Change the sentence data was extracted…. to data were extracted…

Response: Thank you, dear reviewer. We revised it.

Studies that utilized other (PHQ-9, HADS); 30.67% higher than studies that used BDI-II; 26.07 %. Not clear please reorganize this sentence.

Response: Thank you dear reviewer. The measurement tools for depressive symptoms to perform subgroup analysis. The subgroup analysis by assessment instrument yields that measurement with other (PHQ-9, HADS), CEDS’s, and BDI-II. We categorized it for subgroup analysis and the result showed depression assessed using (PHQ-9, HADS) higher than studies BDI-II.

Change aOR to AOR

Conclusion: change Ethipisn to Ethiopia

Response: Thank you for your critical review.

Background

Paragraph 1: guilty feeling repeated twice

Response: We took a measurement.

Paragraph 3: Pakistani to Pakistan

Response: Thank you so much for your critical view.

Paragraph 4: In the context of Ethiopia too….not clear please reconstruct the sentence

Response: We rewrite it again.

Materials and method

Response: Based on your valuable comment. We have reviewed the whole manuscript using PRISMA 2015 checklist.

Please state the searching period correctly from when to when. You write a specific time period i.e. 10th of the October 2022.

Response: Thank you we revised it based on your great view of point. Our search was conducted on October 10, 2022, using electronic libraries in Scopus, PubMed, and EMBASE, as well as manual exploration of the reference lists of articles. We searched for any additional articles until the 10th of October 2022. Under Inclusion Criteria, we added this sentence “All observational studies were conducted by using different study-designed cross-sectional reports from June 2006 up to June 2021 were included.”

In your inclusion and exclusion criteria you stated as studies ………published in a language other than English were excluded. Do you believe that studies conducted other than English language can be conducted and published in Ethiopia? I think there is no study conducted in any other language so please remove this.

Response: Very amazing point of view. We accepted and removed it.

The PRISMA (preferred reporting items for systematic reviews and meta-analyses) standard was used to perform the literature search. This sentence should be removed from this and written as a study protocol before search strategy.

Response: Thank you which is another very constructive suggestion. We amended as per recommendation and see the revised manuscript.

You extract the detailed data using a standardized spreadsheet, what are the detailed data’s. It should be listed.

Response: We revised it exhaustively dear reviewer. Please see the revised document.

Since all the studies included for this systematic review and meta-analysis were crossectional studies, you will be used Newcastle Ottawa quality assessment scale adapted for crossectional studies to assess the quality of the studies rather than Newcastle Ottawa quality evaluation checklist. So you should to assess the quality of each study based on Newcastle Ottawa quality assessment scale adapted for crossectional studies again.

Response: We have assessed the quality again. Thank you.

What is your outcome measurement? The outcome measurement should be explicitly stated before Data synthesis and analysis.

Response: Thank you very much. Based on your valuable comment. We incorporated it.

Outcome measurements

Data analysis

You stated as you used Higgs I2 statistic and Cochran Q-statistics were also utilized to detect heterogeneity. But you did not use Cochran Q-statistics? Why?

Response: Cochran's Q test is a non-parametric statistical test to verify whether k treatments have identical effects. We revised it accordingly. We thank you!

The I2 statistical values of zero, 25, 50, and 75% connote absence, little, moderate, and great heterogeneity, respectively. This is vague please categorize it.

Response: We revised it accordingly. “Thus, percentages I2 statistical values around 0%( I2 0), 25% (I2 25), 50% (I2 50), and 75% (I2 75) would mean absent, low, medium, and high heterogeneity, respectively.” We cited it.

Results

Your systematic review and meta-analysis is conducted in Ethiopia and your search will be studies conducted in Ethiopia. How 2 articles were removed because published other than the English language.

Response: We took the action. Thank you so much

There is a considerable heterogeneity I2 =100%, so you tried to explain the source of heterogeneity using subgroup analysis considering the sample size of each study and the study instrument. Even the source of heterogeneity is not explained, I2 =100%. If the source of heterogeneity is not explained, what you would do? Why you will limit subgroup analysis on sample size and the study instrument

Response: We appreciate all comments, which give an additional body of knowledge. We used a sample size and instrument for subgroup analysis rather than case for depression.

Regards,

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PLoS One. doi: 10.1371/journal.pone.0288597.r003

Decision Letter 1

Wudneh Simegn

14 Jun 2023

PONE-D-22-34689R1Prevalence of depression among students at Ethiopian Universities and associated factors: a systematic review and meta-analysis.PLOS ONE

Dear Dr. Anbesaw,

==============================

Avoid Email addresses except the correspondence author in the title page.

Tamrat Anbesaw, Wollo University, College of Medicine and Health 26 Sciences, Department of Psychiatry, Dessie, Ethiopia, should be revised as “*Corresponding author”.

-Authors’ contributions should be prepared based on the journal guideline.

==============================

Please submit your revised manuscript by Jul 29 2023 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.

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'.
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We look forward to receiving your revised manuscript.

Kind regards,

Wudneh Simegn Belay, MSc

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Reviewer #1: Dear authors thank you for accepting and revising this article based on the comments that i raised including the comments from other reviewers. i hope this is an excellent finding for researchers and policy makers who are working on the field of mental health especially among university students. it is helpfull for intervention and planning prior actions before students who join university.

withregards

Reviewer #3: Thank you. All my comments are addressed appropriately.

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

PLoS One. 2023 Oct 12;18(10):e0288597. doi: 10.1371/journal.pone.0288597.r004

Author response to Decision Letter 1

15 Jun 2023

PLOS ONE

PONE-D-22-34689

Article Type: Study Protocol

Title: Prevalence and associated factors of depressive symptoms among Ethiopian University students: a systematic review and meta-analysis

Thank you dear Editor, and Reviewers for your great contribution. We will address the following issues ;

1. Avoid Email addresses except the correspondence author in the title page.

Tamrat Anbesaw, Wollo University, College of Medicine and Health 26 Sciences, Department of Psychiatry, Dessie, Ethiopia, should be revised as “*Corresponding author”.

Response: We removed it.

2. Authors’ contributions should be prepared based on the journal guideline.

Response: We formatted the manuscript using the PLoS ONE style.

Authors contributions

Conceptualization: Tamrat Anbesaw, Yosef Zenebe.

Data curation: Tamrat Anbesaw, Yosef Zenebe, Mogessie Necho,Tesfaye Segon.

Formal analysis: Tamrat Anbesaw, Yosef Zenebe

Funding acquisition: Tamrat Anbesaw, Yosef Zenebe.

Investigation: Tamrat Anbesaw, Yosef Zenebe.

Methodology: Tamrat Anbesaw, Yosef Zenebe, Mogessie Necho, Moges Gebresellassie,Tesfaye Segon, Fasikaw Kebede, Tilahun Bete

Project administration: Tamrat Anbesaw, Yosef Zenebe

Resources: Tamrat Anbesaw, Yosef Zenebe, Mogessie Necho, Moges Gebresellassie,Tesfaye Segon, Tilahun Bete

Software: Tamrat Anbesaw, Yosef Zenebe

Validation: Tamrat Anbesaw, Yosef Zenebe

Writing – original draft: Tamrat Anbesaw

Writing – review & editing: Tamrat Anbesaw, Yosef Zenebe, Mogessie Necho, Tesfaye Segon, Fasikaw Kebede, Tilahun Bete

Attachment

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PLoS One. doi: 10.1371/journal.pone.0288597.r005

Decision Letter 2

Wudneh Simegn

2 Jul 2023

Prevalence of depression among students at Ethiopian Universities and associated factors: a systematic review and meta-analysis.

PONE-D-22-34689R2

Dear Dr. Anbesaw,

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,

Wudneh Simegn Belay, MSc

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0288597.r006

Acceptance letter

Wudneh Simegn

21 Aug 2023

PONE-D-22-34689R2

Prevalence of depression among students at Ethiopian Universities and associated factors: a systematic review and meta-analysis

Dear Dr. Anbesaw:

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.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Wudneh Simegn

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Checklist. PRISMA-P 2015 checklist.

(DOCX)

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S1 Data

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Data Availability Statement

All relevant data from this study will be made available upon study completion.

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PERMALINK

Prevalence of depression among students at Ethiopian universities and associated factors: A systematic review and meta-analysis

Tamrat Anbesaw

Yosef Zenebe

Mogessie Necho

Moges Gebresellassie

Tesfaye Segon

Fasikaw Kebede

Tilahun Bete

Roles

Abstract

Background

Methods

Results

Conclusion

Background

Materials and methods

Study designed

Search strategy

Inclusion and exclusion criteria

Outcome measurements

Data extraction and appraisal of study quality

Data synthesis and analysis

Search results

Identification of studies

Fig 1. PRISMA flow chart for the review search process.

Characteristics of included studies

Quality of included studies

Table 2. Quality assessment result of the studies included in this meta-analysis.

The pooled prevalence of depression among university students

Fig 2. A forest plot for the prevalence of depression.

Subgroup analysis of the prevalence of depression among university students

Subgroup analysis of the prevalence of depression among university students by the sample size

Fig 3. A forest plot for the sub-group analysis of the prevalence of depression based on the sample size of studies.

Subgroup analysis of the prevalence of depression among university students by the tools

Fig 4. Forest plot for the sub-group analysis of the prevalence of depression by measurement tool used.

Sensitivity analysis

Fig 5. Sensitivity analysis for the prevalence of depression among university students.

Publication bias

Fig 6. A funnel plot for publication bias for depression.

Associated factors for depression among students at Ethiopian universities

Table 3. Characteristics of associated factors for depression among university students in Ethiopia by their odds ratio, confidence interval, association strength, author, and year of publication.

Table 4. A pooled estimate of the associated factors for depression among students in Ethiopian universities.

Discussion

Strengths and limitations

Implications of this study for clinical practice, researchers, and policymakers

Conclusion

Supporting information

Acknowledgments

List of abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Wudneh Simegn

Roles

Author response to Decision Letter 0

Decision Letter 1

Wudneh Simegn

Roles

Author response to Decision Letter 1

Decision Letter 2

Wudneh Simegn

Roles

Acceptance letter

Wudneh Simegn

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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