Sample

The Puertas Project, conducted in six Mexican universities, included 4 189 male and female incoming first-year students with completed surveys. This was a census design in which all incoming students for the 2016-2017 academic year were invited to participate in a web-based self-report survey. Universities were chosen based on their interest in early detection of mental health problems. The following six universities of four different states in Mexico participated: Universidad Autónoma de Aguascalientes, Universidad Politécnica de Aguascalientes, Universidad De La Salle Bajío campus Campestre, Universidad De La Salle Bajío campus Salamanca, Universidad La Salle Noroeste, and Universidad La Salle Pachuca. The first two are public, and the latter four are private.

Instrument

The instrument was developed for the WHO-WMH-ICS and contains questions based on previously utilized and validated scales with skip logic so that affirmative answers are further probed. The section on self-harm measures broad suicidal ideation, plans, attempts and non-suicidal self-injury with the items of the Self-injurious Thoughts and Behaviors Interview (SITBI)²² and the Columbia-Suicide Severity Rating Scale (C-SSRS),²³ which consist of 22 and 5 items, respectively, and are well-documented in the international literature. Broad suicidal ideation refers to both thoughts of killing oneself and the wish to be dead or to go to sleep and never wake up. A suicide plan refers to having thoughts about the method of how to kill oneself and an attempt refers to purposefully hurting oneself with at least some intent to die. Non-suicidal self-injury refers to deliberately hurting oneself without the intent to die. The mental disorders section is a screening for probable cases and evaluates symptoms of major depressive episodes, broadly defined mania, generalized anxiety disorder, attention deficit hyperactivity disorder (ADHD), and substance use disorders. These disorders were chosen because they have been shown to be among the most frequent among the general population of Mexican adolescents and young adults.^13,20 These symptoms are evaluated for lifetime presence as well as in the prior 12-months, with the exception of ADHD, for which symptoms in the prior six months are evaluated. These screening questions are derived from a self-report version of the Composite International Diagnostic Interview (WMH-CIDI).²⁴ The WMH-CIDI has shown adequate concordance with clinician-administered interviews with the SCID²⁵ and it has been widely used in Mexico,^20,26 following a rigorous process of translation and adaptation.²⁷ The socio-demographic variables reported in this article include: gender (self-identification as male, female or other), age, public versus private university, parental education (classified by the highest level of education obtained by the parent with more education), parents’ marital status (classified as both married and alive versus not married or deceased), current living situation (classified as living with parents or family, with roommates, or on one’s own), religion (Catholic/Christian, other or none), sexual orientation (non-heterosexual [gay, lesbian, bisexual, asexual, not sure] versus heterosexual) and working in addition to studying for any number of hours per week. Service use was measured by a series of questions which asked about current, 12-month and lifetime treatment for an emotional or substance problem, whether the treatment was psychological counseling or medication, and willingness to seek services within and outside their university should they, during the coming school year, develop an emotional problem that would cause them a lot of distress or interference with school work (dichotomized into definitely/probably would go versus might or might not/probably not/ or definitely would not go).

Procedures

While overall procedures were similar across universities, recruitment varied by university. At Universidad Autónoma de Aguascalientes, the survey was administered during the “health week” for new students, in which students were administered other general health questionnaires. They were given the survey link, a tablet, and the space and time to respond to the survey. At Universidad Politécnica de Aguascalientes, all first-year students take a class on personal and professional development, and they were invited to participate and given the link by their tutors as well as time to answer during class. Their tutors later gave reminders to their tutees. At Universidad De La Salle Bajío, Salamanca and Campestre campuses, all first-year students were invited and given the link as well as time and space to participate during teacher evaluations at the end of the semester. At Universidad La Salle Pachuca, all first-year students were invited and given the link during a personal development class. The faculty of that course later gave reminders to their students. Finally, at Universidad La Salle Noroeste, all first-year students were invited and given the link and time and space to participate during a technology tools class. The overall response rate (the number of students with completed surveys/ the number of total incoming first-year students as reported by each university) was 79.3%, varying from 44.2 to 90.8% in individual universities.

Ethical considerations

The Research Ethics Committee of the National Institute of Psychiatry approved the research protocol. Participation was confidential and voluntary. Informed consent was obtained from participants through the web platform. Only students aged 18 or above were eligible to participate. For all the participants who answered affirmatively to depressive symptomatology, alcohol or drug problems, STB or non-suicidal self-injury and those experiencing an extremely stressful event in the prior year, an automatic message was displayed providing them information of where they could obtain professional help. University-based, community-based and online options were provided.

Statistical analyses

Based on the age and sex distributions of the incoming students provided by each university, sample weights were calculated to ensure that the sample was representative of the total incoming student class. Thus, estimated proportions were weighted to adjust for differential responses by age and sex within each university. Prevalence estimates are reported as unweighted numbers (n), weighted proportions (%), and standard errors (SE). Chi square analysis was performed to evaluate differences in the prevalence between men and women. Associations between socio-demographic correlates and psychopathology were estimated with multivariate logistic regression equations. Analyses were conducted with Stata software.^‡

Problems faced by incoming university students

The results of this study show that almost one in three incoming first year students arrives at university having experienced some type of emotional, substance-related or behavioral problem in the past. While most of these students have experienced only one probable mental disorder, a small group has experienced two (8.7%) or even three or more (4.9%) probable disorders. Furthermore, many have experienced self-harm, thus putting their lives at risk. While a greater proportion has had suicidal ideation (23.0%), a smaller proportion has attempted suicide (3.5%). These estimates are remarkably similar to the 22.3% and 3.2% reported for suicidal ideation and attempt in a recent meta-analysis of university students from North America, Asia, Europe and Africa, though no study from Latin America was included.²⁸ In regard to previous studies of university students in Mexico, González-Macip and colleagues²⁹ reported an estimated 18.9% with suicidal ideation (an estimate slightly lower than ours, though perhaps using a less broad definition of ideation), while Unikel and colleagues cited 10% of a small non representative sample of female university and high school students.³⁰ These estimates are all much lower than the 47% with suicidal ideation and 9% with an attempt cited in a representative study of high school students in Mexico, indicating perhaps that many high school students with suicidality may not go on to college.³¹ Few studies have reported the prevalence of psychopathology in Mexican university students; according to one of these, 36% of medical students reported depressive symptomatology.³² Strunin and colleagues³³ found changes in alcohol use (both increases and decreases) among incoming first-year university students in Mexico City. Decreases among previously excessive or heavy drinkers were related to new obligations and lack of time as well as friendship changes. Increased drinking behaviors among previously occasional and regular drinkers were related to increased autonomy and changes in friendships.

Who are the distressed students?

Females screened positive for more disorders, suicidal thoughts and self-harm behaviors, and most types of disorders, with the exception of ADHD and mania, for which there were no sex differences, and substance disorders, which were more prevalent among male students. This is consistent with prior studies on sex differences for specific disorders.^20,21

Older students were found to have greater odds of psychopathology (though not suicidal thoughts or self-harm behaviors). The fact that psychopathology is more frequent among older students might be explained by mental disorders influencing their delay in obtaining university admission or entrance, though this is speculative and cannot be determined from this study due to its cross-sectional nature. Regardless of the cause, these results suggest that older students might be a target for intervention, or at the very least for screening, during the transition to college.

Family characteristics were important correlates of psychopathology and suicidal thoughts and self-harm behaviors, particularly the educational level and marital status of parents; thus, students of college-educated parents had lower odds, while students of not married or deceased parents had higher odds. Prior research has found that first-generation university students may have greater difficulty adjusting to college, resulting in increased depressive symptoms and reduced well-being.³⁴ This might be due to both family achievement guilt and socio-economic factors. Similarly, the impact of parental separation and death are likely to involve both socio-emotional and socioeconomic aspects.^35,36

Consistent with our findings in Mexican university students, a systematic review of mental disorders, suicide and deliberate self-harm in sexual minorities, reported a two-fold risk of suicide ideation and attempts, and a 1.5 risk for depression and anxiety disorders and substance dependence in non-heterosexual individuals in comparison with heterosexuals.³⁷ This greater risk is likely due to the impact of discrimination, victimization, social stress and internalized homophobia on emotional wellbeing.³⁸

Religion has been found to protect against suicidal behavior, though the evidence is inconsistent and often depends upon different dimensions of religion, such as affiliation, practice, and spirituality. A recent systematic review has found that religious affiliation (which is what we included in this study) does not necessarily protect against ideation; however, it does protect against attempt, and this protection against attempt is dependent upon culturally specific implications of affiliating with a particular religion.³⁹ In this study we found that having no religious affiliation or a non-Catholic/Christian affiliation was associated to increased risk of both suicidal behavior and overall psychopathology, which could be due to the social support provided by having a religious affiliation and/or to the Catholic religion´s teachings on suicide.

While both public and private universities must contend with similar rates of suicidal behavior, these findings suggest that the students of the public universities that participated in this study had greater risk for probable mental disorders than those from the participating private universities. It is not possible to determine whether this is due to the characteristics of the specific universities in this study or is generalizable to all public and private universities, as the participating universities were not randomly selected. Important differences between the public and private universities which participated in this study include size, whether the universities were religious or not, and their geographic location, all of which could account for these differences.

Treatment possibilities for university students

Because psychopathology, substance abuse and suicidal thoughts and self-harm behaviors are likely to influence students´ transition to university and academic success, and because university students are accessible and contained, detection, referral and treatment of students upon entry to university is important and feasible. While almost 70% of students with a probable lifetime disorder have not received any lifetime treatment, a majority of students state that they would be willing to seek treatment on campus for university-based services and, to a lesser extent, off campus. Not all universities provide such services for their students. Some of our universities that don´t have mental health services have tutoring programs that can serve as a gateway for detecting and referring students. A study of university undergraduates in a Canadian university found three groups of student preferences for services: a group (45.5%) that preferred university-based psychological or psychiatric professional services, a group that preferred alternative services (39.3%) such as peer counseling or e-mental health options, and a small hesitant group (15.2%) that would prefer not to seek help even though clearly distressed.⁴⁰ Interestingly, in our study, the proportion of students with probable 12-month disorders who have received services is lower than the proportion of students who say they would seek services if they had a mental health problem. This may be due to students not recognizing that they have a problem, not knowing where to find services, the lack of services or barriers to service use.

Limitations

Certain limitations should be considered. Prevalence estimates are based on a self-report web-based survey rather than a comprehensive clinical diagnostic interview and therefore should be considered a screening of possible cases rather than a confirmed diagnosis. Furthermore, while we utilized internationally used and validated scales, we do not have data on the validity for Mexican youth specifically. While the overall participant response rate was quite good (compared to the 44% response rate of an online survey of college students in 26 universities of the United States),⁴¹ and the universities included were both public and private, located in four different states, they were not randomly selected and therefore the study participants are not representative of all university students in Mexico. Finally, because this is a cross-sectional survey, disorder correlates are associations for which no causality or directionality can be attributed.