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Non-suicidal self-injury (NSSI) is associated with mental disorders, yet work regarding the direction of this association is inconsistent. We examined the prevalence, comorbidity, time-order associations with mental disorders, and sex differences in sporadic and repetitive NSSI among emerging adults. We used survey data from = 72,288 first-year college students as part of the World Mental Health-International College Student Survey Initiative (WMH-ICS) to explore time-order associations between onset of NSSI and mental disorders, based on retrospective age-of-onset reports using discrete-time survival models. We distinguished between sporadic (1-5 lifetime episodes) and repetitive (≥6 lifetime episodes) NSSI in relation to mood, anxiety, and externalizing disorders. We estimated a lifetime NSSI rate of 24.5%, with approximately half reporting sporadic NSSI and half repetitive NSSI. The time-order associations between onset of NSSI and mental disorders were bidirectional, but mental disorders were stronger predictors of the onset of NSSI (median RR = 1.94) than vice versa (median RR = 1.58). These associations were stronger among individuals engaging in repetitive rather than sporadic NSSI. While associations between NSSI and mental disorders generally did not differ by sex, repetitive NSSI was a stronger predictor for the onset of subsequent substance use disorders among females compared to males. Most mental disorders marginally increased the risk for persistent repetitive NSSI (median RR = 1.23). Our findings offer unique insights into the temporal order between NSSI and mental disorders. Further work exploring the mechanism underlying these associations will pave the way for early identification and intervention of both NSSI and mental disorders.

Background Heterogeneity of treatment effects (HTEs) can occur because of either differential treatment compliance or differential treatment effectiveness. This distinction is important, as it has action implications, but it is unclear how to distinguish these two possibilities statistically in precision treatment analysis given that compliance is not observed until after randomization. We review available statistical methods and illustrate a recommended method in secondary analysis in a trial focused on HTE. Methods The trial randomized n = 880 anxious and/or depressed university students to guided internet‐delivered cognitive behavioral therapy (i‐CBT) or treatment‐as‐usual (TAU) and evaluated joint remission. Previously reported analyses documented superiority of i‐CBT but significant HTE. In the reanalysis reported here, we used baseline (i.e., pre‐randomization) covariates to predict compliance among participants randomized to guided i‐CBT, generated a cross‐validated within‐person expected compliance score based on this model in both intervention groups, and then used this expected composite score as a predictor in an expanded HTE analysis. Results The significant intervention effect was limited to participants with high expected compliance. Residual HTE was nonsignificant. Conclusions Future psychotherapy HTE trials should routinely develop and include expected compliance composite scores to distinguish the effects of differential treatment compliance from the effects of differential treatment effectiveness.

We seek to evaluate whether Internet Gaming Disorder (IGD) among university students in Mexico during their first year at university predicts a long list of mental disorders a year later, controlling for baseline mental health disorders as well as demographics. This is a prospective cohort study with a one-year follow-up period conducted during the 2018–2019 academic year and followed up during the 2019–2020 academic year at six Mexican universities. Participants were first-year university students (n = 1741) who reported symptoms compatible with an IGD diagnosis at entry (baseline). Outcomes are seven mental disorders (mania, hypomania, and major depressive episodes; generalized anxiety disorder and panic disorder; alcohol use disorder and drug use disorder), and three groups of mental disorders (mood, anxiety, and substance use disorders) at the end of the one-year follow-up. Fully adjusted models, that included baseline controls for groups of mental disorders, rendered all associations null. The association between baseline IGD and all disorders and groups of disorders at follow-up was close to one, suggesting a lack of longitudinal impact of IGD on mental disorders. Conflicting results from available longitudinal studies on the role of IGD in the development of mental disorders warrant further research.

Half of mental disorders have their first onset before adulthood when the presence of a disorder may be particularly disruptive to developmental milestones. Retrospective prevalence estimates have been shown to underestimate the burden of mental illness and scarce data are available on the incidence of disorders throughout the adolescent period, especially in developing countries. Thus, the objective was to determine the incidence of mental disorders in an 8-year period from adolescence to young adulthood, onset of service use and their predictors in a Mexican cohort. 1071 respondents from a representative two-wave panel sample participated in the Mexican Adolescent Mental Health Survey in 2005 and in the follow-up survey in 2013. Disorders were evaluated with the World Mental Health Composite International Diagnostic Interview. 37.9 % experienced the onset of a psychiatric disorder and 28.4 % sought services for the first time. Substance use disorders had the greatest incidence, followed by mood and behavior disorders, anxiety disorders and lastly eating disorders. Sex, age, school dropout, childhood adversities and prior mental disorders predicted the onset of new disorders. Being female, having more educated parents and most classes of disorder predicted first time service use. These findings contribute to a paradigm shift in conceptions of mental disorder similar to how we think of common physical afflictions as near universal experiences across the life course, but less frequent at any given moment. Adolescents are particularly vulnerable. Therefore, public health policy should focus on early universal promotion of positive mental health and structural determinants of mental health.

Background Major depressive disorder (MDD) and generalized anxiety disorder (GAD) are highly prevalent among university students and predict impaired college performance and later life role functioning. Yet most students do not receive treatment, especially in low-middle-income countries (LMICs). We aim to evaluate the effects of expanding treatment using scalable and inexpensive Internet-delivered transdiagnostic cognitive behavioral therapy (iCBT) among college students with symptoms of MDD and/or GAD in two LMICs in Latin America (Colombia and Mexico) and to investigate the feasibility of creating a precision treatment rule (PTR) to predict for whom iCBT is most effective. Methods We will first carry out a multi-site randomized pragmatic clinical trial ( N = 1500) of students seeking treatment at student mental health clinics in participating universities or responding to an email offering services. Students on wait lists for clinic services will be randomized to unguided iCBT (33%), guided iCBT (33%), and treatment as usual (TAU) (33%). iCBT will be provided immediately whereas TAU will be whenever a clinic appointment is available. Short-term aggregate effects will be assessed at 90 days and longer-term effects 12 months after randomization. We will use ensemble machine learning to predict heterogeneity of treatment effects of unguided versus guided iCBT versus TAU and develop a precision treatment rule (PTR) to optimize individual student outcome. We will then conduct a second and third trial with separate samples ( n = 500 per arm), but with unequal allocation across two arms: 25% will be assigned to the treatment determined to yield optimal outcomes based on the PTR developed in the first trial (PTR for optimal short-term outcomes for Trial 2 and 12-month outcomes for Trial 3), whereas the remaining 75% will be assigned with equal allocation across all three treatment arms. Discussion By collecting comprehensive baseline characteristics to evaluate heterogeneity of treatment effects, we will provide valuable and innovative information to optimize treatment effects and guide university mental health treatment planning. Such an effort could have enormous public-health implications for the region by increasing the reach of treatment, decreasing unmet need and clinic wait times, and serving as a model of evidence-based intervention planning and implementation. Trial status IRB Approval of Protocol Version 1.0; June 3, 2020. Recruitment began on March 1, 2021. Recruitment is tentatively scheduled to be completed on May 30, 2024. Trial registration ClinicalTrials.gov NCT04780542 . First submission date: February 28, 2021.

To scale up mental health care in low-resource settings, digital interventions must consider cultural fit. Despite the findings that culturally adapted digital interventions have greater effectiveness, there is a lack of empirical evidence of interventions that have been culturally adapted or their adaptation documented. This study aimed to document the cultural adaptation of the SilverCloud Health Space from Depression and Anxiety program for university students in Colombia and Mexico and evaluate user satisfaction with the adapted program. A mixed methods process was based on Cultural Sensitivity and Ecological Validity frameworks. In phase 1, the research team added culturally relevant content (eg, expressions, personal stories, photos) for the target population to the intervention. In phase 2, potential users (9 university students) first evaluated the vignettes and photos used throughout the program. We calculated median and modal responses. They then participated in focus groups to evaluate and assess the cultural appropriateness of the materials. Their comments were coded into the 8 dimensions of the Ecological Validity Framework. Phase 3 consisted of choosing the vignettes most highly rated by the potential users and making modifications to the materials based on the student feedback. In the final phase, 765 actual users then engaged with the culturally adapted program and rated their satisfaction with the program. We calculated the percentage of users who agreed or strongly agreed that the modules were interesting, relevant, useful, and helped them attain their goals. The potential users perceived the original vignettes as moderately genuine, or true, which were given median scores between 2.5 and 3 (out of a possible 4) and somewhat identified with the situations presented in the vignettes given median scores between 1.5 and 3. The majority of comments or suggestions for modification concerned language (126/218, 57.5%), followed by concepts (50/218, 22.8%). Much less concerned methods (22/218, 10%), persons (9/218, 4.1%), context (5/218, 2.3%), or content (2/218, 0.9%). There were no comments about metaphors or goals. Intervention materials were modified based on these results. Of the actual users who engaged with the adapted version of the program, 87.7%-96.2% of them agreed or strongly agreed that the modules were interesting, relevant, useful, and helped them to attain their goals. We conclude that the adapted version is satisfactory for this population based on the focus group discussions and the satisfaction scores. Conducting and documenting such cultural adaptations and involving the users in the cultural adaptation process will likely improve the effectiveness of digital mental health interventions in low- and middle-income countries and culturally diverse contexts.

The first year of college may carry especially high risk for onset of alcohol use disorders. We assessed the one-year incidence of alcohol use disorders (AUD) among incoming first-year students, predictors of AUD-incidence, prediction accuracy and population impact. A prospective cohort study of first-year college students (baseline: N = 5843; response rate = 51.8%; 1-year follow-up: n  = 1959; conditional response rate = 41.6%) at a large university in Belgium was conducted. AUD were evaluated with the AUDIT and baseline predictors with the Composite International Diagnostic Interview Screening Scales (CIDI-SC). The one-year incidence of AUD was 3.9% (SE = 0.4). The most important individual-level baseline predictors of AUD incidence were being male (OR = 1.53; 95% CI = 1.12–2.10), a break-up with a romantic partner (OR = 1.67; 95% CI = 1.08–2.59), hazardous drinking (OR = 3.36; 95% CI = 1.31–8.63), and alcohol use characteristics at baseline (ORs between 1.29 and 1.38). Multivariate cross-validated prediction (cross-validated AUC = 0.887) shows that 55.5% of incident AUD cases occurred among the 10% of students at highest predicted risk (20.1% predicted incidence in this highest-risk subgroup). Four out of five students with incident AUD would hypothetically be preventable if baseline hazardous drinking was to be eliminated along with a reduction of one standard deviation in alcohol use characteristics scores, and another 15.0% would potentially be preventable if all 12-month stressful events were eliminated. Screening at college entrance is a promising strategy to identify students at risk of transitioning to more problematic drinking and AUD, thus improving the development and deployment of targeted preventive interventions.

PurposeMental health disparities have been documented among sexual minority college students, but there is a dearth of evidence from developing countries. The aim is to estimate the prevalence of 12-month mental and substance use disorders across a range of sexual identities among first-year college students in Mexican universities, and test whether there is an association between sexual identity and disorders and whether the association is moderated by gender.MethodThe University Project for Healthy Students, a web-based survey conducted as part of the World Health Organization’s World Mental Health International College Student initiative, recruited 7874 students from nine Mexican universities in 2016 and 2017. Logistic regressions estimated the association of sexual identity with 12-month major depressive episode, generalized anxiety disorder, panic disorder, alcohol abuse/dependence, and drug abuse/dependence, with interaction terms for gender.ResultsCompared to heterosexual students reporting no same-sex attraction (SSA), heterosexual students with SSA (AORs range 1.77–3.67) and lesbian/gay and bisexual students (AORs range 2.22–5.32) were at a higher risk for several disorders. Asexual students were at higher risk for drug abuse/dependence (AOR = 3.64). Students unsure of their sexual identity were at a higher risk for major depressive episode, panic disorder, and drug abuse/dependence (AORs range 2.25–3.82). Gender differences varied across sexual identity and disorder.ConclusionThese findings are the first empirical report of sexual minority psychiatric disparities among a college student population from a developing nation and underscore the importance of clinical interventions that address mental health needs among sexual minority college students.