Mental Health and Alcohol Consumption Among University Students in the Post-Pandemic Context: An Exploratory Cross-Sectional Study in Portugal

Round 1

Reviewer 1 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

Having had the opportunity to reread the article, I believe that the changes made are consistent with the previous comments and, therefore, I think it can be accepted in present form.

Author Response

Having had the opportunity to reread the article, I believe that the changes made are consistent with the previous comments and, therefore, I think it can be accepted in present form.

R: We would like to express our sincere gratitude to the reviewer for the careful re-evaluation of the manuscript. We are pleased to learn that the revisions undertaken were considered consistent with the previous comments and that the manuscript is now regarded as suitable for acceptance in its current form. We greatly appreciate the reviewer’s constructive feedback, which has been instrumental in improving the clarity, structure, and scientific quality of the article.

Thank you for your valuable contribution to the peer-review process.

 

 

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

The manuscript addresses an important and timely topic concerning mental health and alcohol consumption among university students in the post-pandemic period. While the study provides interesting insights, several major issues require clarification or substantial revision.

Grammatical and typographical errors should be corrected throughout the manuscript.

The manuscript uses the term “gender” inconsistently and inaccurately in contexts where the authors clearly refer to biological sex. Since the study did not assess gender identity and the categories presented (“female/male”) correspond to sex, not gender, the terminology should be corrected throughout the manuscript.

References to Costa et al. (2023) appear twice.

Only a very small fraction of participants fell into moderate/high AUDIT risk groups. Logistic regression with such an imbalanced outcome is statistically unstable. Please provide justification for using regression given the small event count.

The Introduction provides a solid overview of burnout and lifestyle-related factors but lacks contextualization within the post-pandemic period. The rationale would be strengthened if the authors briefly discussed emerging evidence on the persistent impacts of the COVID-19 pandemic on both mental and physical health in young adults. For example, studies such as “Long-term consequences of COVID-19 on mental and physical health in young adults” highlight that even after the acute phase, many young individuals continue to experience changes in mood, fatigue, and physical functioning, which may interact with lifestyle behaviors such as sleep, diet, and activity patterns. Integrating this context would help situate the present study within a broader global health perspective. In recent years, the pandemic has become a critical factor influencing the lifestyle, coping strategies, and psychological well-being of young adults. The authors are encouraged to address the pandemic as a modifying factor in student behavior and alcohol consumption. For instance, the study “Effect of COVID-19 pandemic on lifestyle and bone mineral density in young adults” reported a significant reduction in the prevalence of alcohol consumption from 93% before the pandemic to 88.3% during it (p = .024). Including such evidence would enhance the contextual relevance of the Introduction.

The manuscript frequently refers to "DASS-42", although the questionnaire administered was DASS-21 with values multiplied by two. This should be clearly stated earlier and referenced consistently.

The Discussion section is excessively long and contains extensive background on pandemic-related mental health literature, much of which is only loosely connected to the study’s actual findings.

Statements about the “protective effects” of living away from home are given; however, due to the small sample size and lack of confounder control, these results should be expanded to more clearly acknowledge methodological constraints, including issues related to sampling and study design.

Comments on the Quality of English Language

The overall quality of English should be improved to ensure clearer and more precise communication of the research aims, methods, and findings. Several sections contain grammatical inconsistencies, overly complex phrasing, and imprecise terminology, which may hinder readers’ understanding. A thorough language revision—preferably by a native speaker or professional editor—is recommended to enhance clarity, cohesion, and academic style throughout the manuscript.

Author Response

Response to Reviewer

We sincerely thank the reviewer for the careful evaluation of our manuscript and for the constructive and detailed comments. We greatly appreciate the reviewer’s insights, which have helped improve the manuscript's clarity, methodological transparency, and contextual relevance. Below, we address each comment point by point and describe how it has been addressed in the revised version.

 

Comment 1

“Grammatical and typographical errors should be corrected throughout the manuscript.”

Response:

The manuscript has undergone a thorough language revision to correct grammatical, typographical, and stylistic issues. Sentence structure was simplified where necessary, terminology was standardised, and clarity was improved across all sections. We believe the revised version now reflects a clearer and more consistent academic writing style.

 

Comment 2

“The manuscript uses the term ‘gender’ inconsistently and inaccurately where biological sex is clearly intended.”

Response:

We thank the reviewer for highlighting this important issue. The terminology has been corrected throughout the manuscript. The term “sex” is now consistently used when referring to biological categories (“female/male”), and all inappropriate or inconsistent references to “gender” have been replaced accordingly. As gender identity was not assessed in this study, no interpretations related to gender were retained.

 

Comment 3

“References to Costa et al. (2023) appear twice.”

Response:
We acknowledge this oversight. The duplicated reference to Costa et al. (2023) has been corrected, and the reference list has been carefully reviewed to ensure that all citations now appear only once and are consistently referenced throughout the manuscript.

 

Comment 4

“Only a very small fraction of participants fell into moderate/high AUDIT risk groups. Logistic regression with such an imbalanced outcome is statistically unstable. Please provide justification.”

Response:

We appreciate this essential methodological observation. In the revised manuscript, we have explicitly justified the use of binomial logistic regression in the Methods and Limitations sections. The analysis was conducted with an exploratory aim, acknowledging the small number of cases in higher AUDIT risk categories. We now clearly state that the regression results should be interpreted with caution due to outcome imbalance, limited event counts, and sample size constraints. This limitation is explicitly discussed as a potential source of instability in the estimates, and the findings are framed as indicative rather than confirmatory. Furthermore, the reduction in the number of predictors aimed to reduce the number of events per variable, improving estimates and reducing instability.

 

Comment 5

“The Introduction lacks contextualization within the post-pandemic period and emerging evidence on persistent impacts of COVID-19 on young adults.”

Response:

We fully agree and have substantially revised the Introduction to address this point. The revised version now explicitly situates the study within the post-pandemic period of academic reintegration, highlighting evidence that the psychological and behavioural effects of COVID-19 persist beyond the acute phase. We strengthened the rationale by discussing how prolonged emotional distress, fatigue, and changes in lifestyle behaviours may continue to shape alcohol consumption patterns among young adults. The pandemic is now explicitly framed as a modifying factor influencing student behaviour, coping strategies, and health-related outcomes, thereby strengthening the study's global and post-pandemic relevance.

 

Comment 6

“The manuscript frequently refers to ‘DASS-42’, although the questionnaire administered was DASS-21.”

Response:

We thank the reviewer for identifying this issue. The manuscript has been revised to clarify this point early in the Methods section. It is now clearly stated that the DASS-21 was administered, and that the scores from each subscale were multiplied by two and then added to allow comparison with the original DASS-42 scale, in accordance with established guidelines. Terminology has been standardised throughout the manuscript to avoid ambiguity.

 

Comment 7

“The Discussion section is excessively long and contains extensive background loosely connected to the findings.”

Response:

The Discussion section has been substantially restructured and shortened. Redundant background information and overly general pandemic-related literature were removed. The revised Discussion now focuses more directly on interpreting the study’s findings, linking results to theory, context, and existing evidence, and clearly distinguishing between interpretation and speculation.

 

Comment 8

“Statements about the protective effects of living away from home should more clearly acknowledge methodological constraints.”

Response:

In the revised Discussion and Limitations sections, statements regarding the protective role of living away from home have been carefully tempered. We now explicitly acknowledge the exploratory nature of this finding, the small sample size, potential confounding factors, and the limitations inherent to the cross-sectional design. The result is presented as a hypothesis-generating observation rather than a definitive protective effect.

 

Comments on the Quality of English Language

Response:

We acknowledge the reviewer’s concerns regarding language quality. As noted above, the manuscript has undergone a comprehensive language revision to improve clarity, precision, and academic tone. Terminology has been standardised, complex phrasing simplified, and coherence improved across sections. We are confident that these revisions substantially enhance readability and overall quality.

 

Final remarks

We are grateful to the reviewer for the insightful and constructive feedback, which has allowed us to improve the manuscript significantly. The revised version now addresses all major concerns and presents a clearer, more methodologically transparent, and contextually grounded contribution to the literature on post-pandemic student health.

We thank the reviewer for their careful reading of our manuscript and for the constructive and insightful comments. These suggestions significantly improved the manuscript's clarity, focus, and scientific quality. Below, we address each point in the comment. All changes have been incorporated into the revised version of the manuscript.

Reviewer 3 Report (New Reviewer)

Comments and Suggestions for Authors

In my opinion, the article requires fundamental revisions. Both the introduction and the discussion contain too many repetitions. Sometimes, the same themes of thought (content) are written differently, but the text is also different. Both the introduction and, especially, the discussion are too long. The content is not directly related to the research objective. If the authors had clearly and specifically stated their hypotheses, it would have been easier to organize the discussion.

The student sample is indeed too small. In this case, the article will only be meaningful if the authors actually (and not just, as they declare, announce, or wishfully) describe this research in the Portuguese cultural context. Unfortunately, this is not included in this article. The specific lifestyle of Portuguese students should be presented in depth in the introduction or a separate section. This context should be addressed in the discussion chapter.
The methods chapter should be divided into subsections. Line 179 - incorrect citation.
The presentation of results lacks a detailed table with the logistic regression results.
Conclusions must directly address the aim of the work and the results obtained from this research.

Author Response

Response to Reviewer

We sincerely thank the reviewer for the thorough and critical evaluation of our manuscript. We greatly appreciate the constructive nature of the comments, which highlighted important structural and conceptual issues. In response, we undertook substantial revisions that significantly improved the article's focus, coherence, and scientific contribution. Below, we address each point of the comment in detail.

 

Comment 1

“The article requires fundamental revisions. Both the introduction and the discussion contain too many repetitions, are too long, and are not directly related to the research objective. The lack of clearly stated hypotheses makes the discussion difficult to organise.”

Response:

Both the Introduction and the Discussion were substantially rewritten to eliminate repetitions, improve coherence, and ensure direct alignment with the research objectives.

The Introduction was shortened and restructured to focus specifically on:

(i) post-pandemic psychological distress among university students,

(ii) alcohol consumption as a health-related behaviour, and

(iii) the relevance of the Portuguese academic context.

 

In addition, explicit hypotheses were formulated and clearly stated at the end of the Introduction. These hypotheses now directly guide the structure and interpretation presented in the Discussion. The Discussion itself was reorganised into focused subsections centred on the study’s results, avoiding narrative repetition and improving analytical clarity.

 

Comment 2

“The student sample is too small. The article will only be meaningful if the research is clearly described within the Portuguese cultural context, which is currently missing.”

Response:

We acknowledge this concern and addressed it directly in the revised manuscript. The Portuguese cultural and academic context is now explicitly integrated into both the Introduction and the Discussion. We added a detailed description of Portuguese university life, including academic traditions such as praxe and major academic celebrations, and their established association with alcohol consumption.

Furthermore, the Discussion consistently interprets the findings within this cultural framework, explicitly stating that the study’s value lies in its context-specific contribution rather than broad generalisability. This repositioning clarifies the relevance of the findings despite the small sample size and aligns the manuscript with culturally grounded research practices.

 

Comment 3

“The specific lifestyle of Portuguese students should be presented in depth in the introduction or a separate section and addressed in the discussion chapter.”

Response:

This suggestion was fully incorporated. The Introduction now includes an expanded section describing the lifestyle, social norms, and academic traditions of Portuguese university students, supported by national literature. The Discussion revisits this context when interpreting alcohol consumption patterns and mental health outcomes, ensuring conceptual consistency throughout the manuscript.

 

Comment 4

“The methods chapter should be divided into subsections.”

Response:

The Methods section has been completely reorganised into clear and standardised subsections, including study design and participants, data collection procedures, instruments, statistical analysis, and ethical considerations. This restructuring improves readability, methodological transparency, and alignment with journal standards.

 

Comment 5

“Line 179 – incorrect citation.”

Response:

We thank the reviewer for identifying this issue. The incorrect citation was reviewed and corrected. All references related to measurement instruments and methodological descriptions were carefully rechecked to ensure accuracy and consistency throughout the manuscript.

 

Comment 6

“The presentation of results lacks a detailed table with the logistic regression results.”

Response:

Dear reviewer, thank you for your comment and careful consideration, table 4 with detailed information from the logistic regression was included to improve clarity.

 

Comment 7

“Conclusions must directly address the aim of the work and the results obtained from this research.”

Response:

The Conclusions section was substantially revised to reflect the study aims and key findings directly. The revised version explicitly summarises the association between psychological distress and alcohol-use risk, highlights the role of living arrangements, and emphasises the relevance of these findings within the Portuguese post-pandemic academic context.

 

Final remarks

We are grateful for the reviewer’s insightful and rigorous feedback, which prompted substantial improvements to the manuscript. We believe that the revised version now presents a clearer, more focused, and contextually grounded contribution that fully addresses the reviewer’s concerns.

Round 2

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

I would like to thank the authors for their thorough revision of the manuscript and for adequately addressing the majority of the reviewer comments. The manuscript has improved in terms of clarity, structure, and overall scientific quality.

At this stage, I recommend minor revision only. The Introduction provides a solid overview of burnout and lifestyle-related factors but lacks contextualization within the post-pandemic period. The rationale would be strengthened if the authors briefly discussed emerging evidence on the persistent impacts of the COVID-19 pandemic on both mental and physical health in young adults. For example, studies such as “Long-term consequences of COVID-19 on mental and physical health in young adults” highlight that even after the acute phase, many young individuals continue to experience changes in mood, fatigue, and physical functioning, which may interact with lifestyle behaviors such as sleep, diet, and activity patterns. Integrating this context would help situate the present study within a broader global health perspective. In recent years, the pandemic has become a critical factor influencing the lifestyle, coping strategies, and psychological well-being of young adults. The authors are encouraged to address the pandemic as a modifying factor in student behavior and alcohol consumption. For instance, the study “Effect of COVID-19 pandemic on lifestyle and bone mineral density in young adults” reported a significant reduction in the prevalence of alcohol consumption from 93% before the pandemic to 88.3% during it (p = .024). Including such evidence would enhance the contextual relevance of the Introduction.

Author Response

We thank the reviewer for this valuable suggestion. In response, we have revised the Introduction to strengthen the post-pandemic contextualization of the study. A new paragraph has been added that explicitly addresses emerging evidence on the persistent mental and physical health effects of COVID-19 in young adults and their influence on lifestyle behaviours, including alcohol consumption. This addition situates the present study within the broader global context of post-pandemic student health and behavioural adaptation.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The paper presented is extremely relevant given the need for a more in-depth analysis of the effects of alcohol consumption in the university students' mental health.

Still, I'll leave a few brief notes:

1- I suggest correcting a typo in line 24 ‘depression’;

2- Does it make sense to look at the reality of alcohol consumption, dissociating it, for example, from the fact that it is also considered as a kind of "tradition" as pointed out in a government report in Portugal? (Lopes, J. T., & Sebastião, J. (2017). A Praxe como Fenómeno Social. Relatório Final. Direcção-Geral do Ensino Superior (DGES)).

3- For example, when the authors state that students associations can be part of the solution (lines 276 and 277), couldn't alcohol consumption also be seen as a ritual of integration into the group and one of the causes of the problem?

4- I think it's important not to exclude from this framework the phenomenon of binge drinking, that has also been pointed out in the Portuguese university reality: Trigo, A. C., & Santiago, L. M. (2022). Consumo de álcool nos estudantes do ensino superior de Coimbra e o impacto das festas académicas. Acta medica portuguesa, 35(4), 249-256.

Congratulations and thank you for the opportunity to read your work.

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript examining how mental health is linked to problematic alcohol use following the COVID-19 pandemic. The article was interesting to read and covers an important topic. However, the literature is saturated with articles covering how COVID-19 and lockdown restrictions impacted mental health and alcohol consumption, and in the current state it is unclear how this manuscript uniquely contributes to this extensive research base. I believe the manuscript has potential to be published, particularly if the authors can highlight the novelty of their study compared to other work. I have outlined my suggestions and comments below:

 

• Abstract is very brief, a bit more details about the rationale and background of the study would be appreciated beyond the brief aims.
• A bit more discussion and focus about the time of collecting this data in relation to the COVID-19 pandemic is needed, as the authors state data was collected in Portugal in November 2021. Given the different timeframes for easing out of lockdowns globally, a bit more context is needed to understand how alcohol consumption may have changed due to the pandemic.
• More broadly, the results should be interpreted more cautiously given this is a cross-sectional design which does not have a true comparison for pre-lockdown levels of alcohol consumption or mental health. Instead, the authors seem to draw from other statistics and data, from several different countries, to compare their levels of alcohol consumption against which has serious limitations given the relatively small sample size (80 participants).
• Can the authors provide more detail on how they calculated sample size, including any relevant studies that may have informed their decision and their data collection stopping rules.
• A more detailed overview of the importance of higher education and university culture promoting alcohol consumption is needed, as this is only briefly discussed and not in great detail. Additional rationale is needed to understand why this population is at greater risk compared to their non-university peers.
• Some claims are overstating potential relationships between COVID-19 pandemic, mental health, and alcohol consumption (e.g., “…leading many to resort to substance use). The research on this topic is still ongoing and the relation between COVID-19 and alcohol use is likely more nuanced, dependent on individual factors. So broadly, I would recommend the authors talk a bit more cautiously about these relationships and maybe acknowledge individual differences linked to using substances to cope with pandemic-related stressors.
• It seems like the main contribution to the literature is the fact this study was conducted in Portugal, which is often underrepresented in much of the research on this topic. I would recommend the authors talk about the global impact of COVID-19 on alcohol use, making clear the overarching trends that have been widely reported and how they differ internationally (e.g., US vs UK vs EU, within EU countries, western vs non-western differences). Then I recommend the authors spend a chunk of their introduction on how the COVID-19 pandemic uniquely impacted Portugal, in addition to their drinking trends during lockdown and post-lockdown. A lot of this literature is brought up in the discussion, but I believe having this front-and-centre would make it more clear how this research uniquely contributes to the literature to best inform future interventions and studies on the topic.
• More broadly, the introduction feels very disjointed at points and does not cover much depth of information. There is also no clear theory guiding the study, other than an attempt to understand post-pandemic drinking trends which seem exploratory. It would greatly benefit the paper to draw from existing theories which may better develop their rationale for why people may drink more alcohol following the pandemic (e.g., as a coping mechanism). For example, the authors could discuss the tension reduction hypothesis, or even Cooper’s (1994) drinking motives which highlight reasons for consumption which may uniquely promote/reduce consumption during the COVID-19 lockdowns (e.g., coping vs social motives).
• Some of the language used in the introduction is also unclear, specifics would be appreciated. For example, there is mention of drinking in the previous year. What year? From submission? From when data was collected? Be very explicit when discussing these fluctuations in mental health or alcohol consumption regarding the COVID-19 pandemic to best help readers understand the timeline of the pandemic, and how your study fits within that timeline.
• The results are mostly descriptive and exploratory. There are no clear hypotheses or predictions. In the current state, I do not think the results are of a publishable standard given this is only a cross-sectional study with a small sample size, with no inferential statistics used. I would recommend the authors consider adding some more robust statistical analyses, at minimum something like a multiple regression to best understand how different factors may uniquely contribute toward problematic alcohol use. The authors may also want to consider mediation models which could potentially test the mechanistic influence of stress on problematic alcohol use.
• Lastly, the major limitation of the study is the speculation that consumption assessed post-pandemic (November 2021) suggests increased alcohol use. This study does not have participants’ consumption prior or during the pandemic, instead comparing their small sample to other published research. The authors need to strengthen their rationale for these comparisons to build readers’ confidence that their results are supporting their claims. In the current state, I am not convinced that the authors’ claims are supported by the evidence provided.

Reviewer 3 Report

Comments and Suggestions for Authors

This paper examined anxiety, stress, depression, and alcohol use levels among 80 university students from Portugal. Unfortunately, I do not think this paper is worthy of publication as it currently stands. The biggest reason for this is that the study goal was noted as assessing the impact of the pandemic on these variables of interest, but it only reported cross-sectional assessments of these constructs rather than measuring pre- and post-COVID outcomes for comparison. As such, the major findings presented are simply 1) associations between these constructs and sociodemographic characteristics and 2) the percentage of the 80 students at the school who fell within different levels of the constructs. Neither of these findings can speak to any changes that may or may not have occurred based on the pandemic, are particularly novel, or are helpful for the field at large. Additionally, several of the analyses that were conducted were not correctly done; it is not appropriate to assess associations between categorical and continuous variables using Pearson correlations. Overall, I do not believe the paper provides any kind of substantial or unique contribution to the literature, and thus, I cannot advocate for its publication.