Hepatitis C elimination among people who inject drugs in Mexico during the COVID-19 pandemic.

In 2019, Mexico was one of the first countries in Latin America to commit resources to achieve hepatitis C elimination by 2030. One year after this commitment, the global COVID-19 pandemic diverted attention to address immediate health needs to combat the spread of the disease. As a result, efforts to implement hepatitis C prevention and management programs were indefinitely postponed. Furthermore, populations at high risk of contracting the hepatitis C virus (HCV) and who bear the greatest burden of HCV national epidemic, including people who inject drugs and people who live with human immunodeficiency virus infection, remain exposed to extreme health disparities, which have potentially been exacerbated during the COVID-19 pandemic. In this article, we discuss the potential impact the COVID-19 pandemic has had on HCV elimination efforts in Mexico and the urgent need to resume them, since without these efforts, HCV elimination goals are likely not be achieved in the country by 2030.

En 2019, México fue uno de los primeros países en Latinoamérica en comprometer recursos para eliminar la hepatitis C antes de 2030. Un año después de este compromiso, la pandemia mundial de COVID-19 desvió la atención hacia las necesidades inmediatas de salud para combatir la propagación de esta última. Como resultado, los esfuerzos para implementar programas de prevención y manejo de la hepatitis C se suspendieron indefinidamente. Asimismo, las poblaciones con alto riesgo de contraer el virus de la hepatitis C y que representan el mayor peso de la epidemia nacional, como las personas que se inyectan drogas y las personas que viven con infección por el virus de la inmunodeficia humana, permanecen expuestas a disparidades de salud extremas que potencialmente se han exacerbado durante la pandemia de COVID-19. En este artículo discutimos el impacto potencial que la pandemia de COVID-19 ha tenido sobre los esfuerzos de eliminación de la hepatitis C en México y la necesidad urgente de reanudarlos, ya que sin ellos los objetivos de eliminación no se alcanzarán en el país en 2030.

Eliminación de la hepatitis C en usuarios de drogas inyectadas en México durante la pandemia de COVID-19 / Hepatitis C elimination among people who inject drugs in Mexico during the COVID-19 pandemic

Resumen En 2019, México fue uno de los primeros países en Latinoamérica en comprometer recursos para eliminar la hepatitis C antes de 2030. Un año después de este compromiso, la pandemia mundial de COVID-19 desvió la atención hacia las necesidades inmediatas de salud para combatir la propagación de esta última. Como resultado, los esfuerzos para implementar programas de prevención y manejo de la hepatitis C se suspendieron indefinidamente. Asimismo, las poblaciones con alto riesgo de contraer el virus de la hepatitis C y que representan el mayor peso de la epidemia nacional, como las personas que se inyectan drogas y las personas que viven con infección por el virus de la inmunodeficia humana, permanecen expuestas a disparidades de salud extremas que potencialmente se han exacerbado durante la pandemia de COVID-19. En este artículo discutimos el impacto potencial que la pandemia de COVID-19 ha tenido sobre los esfuerzos de eliminación de la hepatitis C en México y la necesidad urgente de reanudarlos, ya que sin ellos los objetivos de eliminación no se alcanzarán en el país en 2030.

Abstract In 2019, Mexico was one of the first countries in Latin America to commit resources to achieve hepatitis C elimination by 2030. One year after this commitment, the global COVID-19 pandemic diverted attention to address immediate health needs to combat the spread of the disease. As a result, efforts to implement hepatitis C prevention and management programs were indefinitely postponed. Furthermore, populations at high risk of contracting the hepatitis C virus (HCV) and who bear the greatest burden of HCV national epidemic, including people who inject drugs and people who live with human immunodeficiency virus infection, remain exposed to extreme health disparities, which have potentially been exacerbated during the COVID-19 pandemic. In this article, we discuss the potential impact the COVID-19 pandemic has had on HCV elimination efforts in Mexico and the urgent need to resume them, since without these efforts, HCV elimination goals are likely not be achieved in the country by 2030.

Cost-effectiveness of hepatitis C virus (HCV) elimination strategies among people who inject drugs (PWID) in Tijuana, Mexico.

BACKGROUND AND AIMS: In Latin America, Mexico was first to launch a hepatitis C virus (HCV) elimination strategy, where people who inject drugs (PWID) are a main risk group for transmission. In Tijuana, HCV seroprevalence among PWID is > 90%, with minimal harm reduction (HR). We evaluated cost-effectiveness of strategies to achieve the incidence elimination target among PWID in Tijuana. METHODS: Modeling study using a dynamic, cost-effectiveness model of HCV transmission and progression among active and former PWID in Tijuana, to assess the cost-effectiveness of incidence elimination strategies from a health-care provider perspective. The model incorporated PWID transitions between HR stages (no HR, only opioid agonist therapy, only high coverage needle-syringe programs, both). Four strategies that could achieve the incidence target (80% reduction by 2030) were compared with the status quo (no intervention). The strategies incorporated the number of direct-acting anti-viral (DAA) treatments required with: (1) no HR scale-up, (2) HR scale-up from 2019 to 20% coverage among PWID, (3) HR to 40% coverage and (4) HR to 50% coverage. Costs (2019 US$) and health outcomes [disability-adjusted life years (DALYs)] were discounted 3% per year. Mean incremental cost-effectiveness ratios (ICER, $/DALY averted) were compared with one-time per capita gross domestic product (GDP) ($9698 in 2019) and purchasing power parity-adjusted per capita GDP ($4842-13 557) willingness-to-pay (WTP) thresholds. RESULTS: DAAs alone were the least costly elimination strategy [$173 million, 95% confidence interval (CI) = 126-238 million], but accrued fewer health benefits compared with strategies with HR. DAAs + 50% HR coverage among PWID averted the most DALYs but cost $265 million, 95% CI = 210-335 million). The optimal strategy was DAAs + 50% HR (ICER $6743/DALY averted compared to DAAs only) under the one-time per-capita GDP WTP ($9698). CONCLUSIONS: A combination of high-coverage harm reduction and hepatitis C virus treatment is the optimal cost-effective strategy to achieve the HCV incidence elimination goal in Mexico.

Geographical and socioeconomic disparities in opioid access in Mexico, 2015-19: a retrospective analysis of surveillance data.

BACKGROUND: In 2015, Mexico implemented regulatory changes and an electronic system to improve access to prescription opioids. We aimed to investigate trends in opioid dispensing after the implementation of these changes and assess how opioid dispensing varied geographically and by socioeconomic status. METHODS: In this retrospective analysis of prescription medication surveillance data, we analysed dispensing data for group 1 medications (all opioids, including morphine, methadone, hydromorphone, oxycodone, tapentadol, fentanyl, sufentanil, and remifentanil) obtained from the Federal Commission for the Protection against Sanitary Risk database for 32 states and six large metropolitan areas in Mexico. We calculated crude annual opioid prescriptions per 10 000 people at the national, state, and municipal levels. Adapting methods from the report of the Lancet Commission on Palliative Care and Pain Relief, we calculated the need for palliative opioids by state, and then assessed the observed opioid dispensing rates as a percentage of expected need by geographical socioeconomic status. Within the six major metropolitan areas, we mapped the geocoded location of opioid prescriptions and assessed the association between opioid dispensing and socioeconomic status as well as the association between opioid dispensing and time to US border crossing for areas on the US-Mexico border. FINDINGS: Between June 25, 2015, and Oct 7, 2019, opioid dispensing rates increased by an average of 13% (95% CI 6·8-19·6) per quarter (3 months). The overall national opioid dispensing rate during the study period was 26·3 prescriptions per 10 000 inhabitants. States with a higher socioeconomic status had higher opioid dispensing rates than states with lower socioeconomic status (rate ratio [RR] 1·88, 95% CI 1·33-2·58, p=0·00016) after controlling for the estimated opioid requirement per state, the presence of methadone clinics, and the presence of tertiary hospitals and cancer centres. The same association between opioid dispensing and socioeconomic status was observed in the metropolitan areas, and in those metropolitan areas on the US-Mexico border a 20% decrease (RR 0·80, 95% CI 0·75-0·86) in opioid dispensation was observed per each SD increase (SD 17·1 min) in travel time to the border. INTERPRETATION: Measures introduced by the Mexican federal Government to increase opioid access for patients with palliative care needs were only marginally successful in raising opioid prescription rates. Opioid access should be improved for patients with palliative care needs who live in geographical areas of lower socioeconomic status. FUNDING: US National Institutes of Health.

Is hepatitis C virus (HCV) elimination achievable among people who inject drugs in Tijuana, Mexico? A modeling analysis.

BACKGROUND: In 2019, Mexico became the first Latin American country committed to hepatitis C virus (HCV) elimination, but the amount of intervention scale-up required is unclear. In Tijuana, HCV among people who inject drugs (PWID) is high; yet there is minimal and intermittent harm reduction, and involuntary exposure to compulsory abstinence programs (CAP) occurs which is associated with increased HCV risk. We determined what combination intervention scale-up can achieve HCV elimination among current and former PWID in Tijuana. METHODS: We constructed a dynamic, deterministic model of HCV transmission, disease progression, and harm reduction among current and former PWID parameterized to Tijuana (~10,000 current PWID, 90% HCV seropositive, minimal opiate agonist therapy [OAT] or high coverage needle/syringe programs [HCNSP]). We evaluated the number of direct-acting antiviral (DAA) treatments needed from 2019 to achieve elimination targets (80% incidence reduction, 65% mortality reduction by 2030) with: (a) DAAs alone, (b) DAAs plus scale-up of OAT+HCNSP (up to 50% coverage of OAT and HCNSP separately, producing 25% of PWID receiving both), (c) DAAs plus CAP scale-up to 50%. Scenarios examined the number of DAAs required if prioritized to current PWID or provided regardless of current injection status, and impact of harm reduction interruptions. RESULTS: Modeling suggests among ~30,000 current and former PWID in Tijuana, 16,160 (95%CI: 12,770-21,610) have chronic HCV. DAA scale-up can achieve the incidence target, requiring 770 treatments/year (95%CI: 640-970) if prioritized to current PWID. 40% fewer DAAs are required with OAT+HCNSP scale-up to 50% among PWID, whereas more are required with involuntary CAP scale-up. Both targets can only be achieved through treating both current and former PWID (1,710 treatments/year), and impact is reduced with harm reduction interruptions. CONCLUSIONS: Elimination targets are achievable in Tijuana through scale-up of harm reduction and DAA therapy, whereas involuntary CAP and harm reduction interruptions hamper elimination.

Fentanyl is used in Mexico's northern border: current challenges for drug health policies.

BACKGROUND AND AIMS: Results from a recent study among 750 heroin users in three Mexico's northern border cities revealed an increase in white powder availability (also known as China white) and preference for this product among heroin users, as well as a general perception of increased overdose cases among this population. Here, we questioned whether those findings reflect an increased presence of heroin laced with fentanyl, which is associated with greater risks of overdose but that, until now, has not been described in Mexico. DESIGN: We tested fentanyl using highly sensitive test strips in syringe plungers, metal cookers and drug wrappings associated with heroin use. SETTING: Three injection sites in Tijuana, Baja California, México. PARTICIPANTS: Eighty-nine heroin users who interchanged paraphernalia for new syringes. MEASUREMENTS: We tested 59 residues of 'pure' white powder. The rest were white powder with black tar (n = 5) or white powder with crystal meth (n = 9), black tar with crystal meth (n = 1), black tar only (n = 13) and crystal meth only (n = 2). FINDINGS: Users believed that they consumed either white powder heroin, white powder heroin with crystal meth, white powder with black tar heroin or black tar heroin only. Analyses revealed that 93% (n = 55) of the 'pure' white powder samples had fentanyl. All (n = 9) the white powder samples mixed with crystal meth and 40% (n = 2) of the white powder with black tar were also laced with fentanyl. CONCLUSIONS: In a sample of 89 heroin users in Mexico, most white powder heroin users were unknowingly exposed to fentanyl, with fentanyl detected in 93% of white powder samples.

Suicide ideation and behavior in Mexico: Encodat 2016.

OBJECTIVE: To provide updated information regarding the 12-month prevalence and associated sociodemographic factors for suicide ideation and behavior (plan and attempts) to substantiate preventive programs in Mexico. MATERIALS AND METHODS: Cross-sectional nationally representative survey, conducted during 2016 (n=56 877) among those 12-65 years old living in rural, urban and metropolitan dwellings. RESULTS: The prevalence of suicide ideation in the last 12-months was 2.3%, 0.8% of the sample reported a plan and 0.7% reported a suicide attempt. All three outcomes were about two times more common among females and suicide plan and attempt were less common among the elderly (50-65 years old). Suicide attempts were more common in urban than in rural areas. The state of Tabasco showed an increased prevalence of ideation, plan and attempts when compared to national average rates. CONCLUSIONS: Public health measures to diminish and treat suicidal behavior are urgently needed all over the country.

OBJETIVO: Dar información actualizada sobre la prevalencia de 12 meses y los factores sociodemográficos asociados para la ideación y el comportamiento suicida (plan e intentos) para fundamentar programas preventivos en México. MATERIAL Y MÉTODOS: Encuesta transversal representativa a nivel nacional, por sexo y grupos de edad, realizada durante 2016 (n = 56 877) entre personas de entre12 y 65 años de edad en zonas rurales, urbanas y metropolitanas. RESULTADOS: La prevalencia de ideación suicida en los últimos 12 meses fue de 2.3%, 0.8% de la muestra informó un plan y 0.7% informó un intento de suicidio. Los tres resultados fueron aproximadamente dos veces más comunes entre las mujeres y el intento de suicidio fue menos común entre los más viejos (50 a 65 años). Los intentos de suicidio fueron más comunes en las zonas urbanas que en las rurales. El estado de Tabasco mostró una mayor prevalencia de ideas, planes e intentos en comparación con las tasas promedio nacionales. CONCLUSIONES: Es urgente y necesario que existan medidas de salud pública para disminuir y tratar el comportamiento suicida en todo el país.

Suicide ideation and behavior in Mexico: Encodat 2016 / Ideación e intento de suicidio en México: Encodat 2016

Abstract: Objective: To provide updated information regarding the 12-month prevalence and associated sociodemographic factors for suicide ideation and behavior (plan and attempts) to substantiate preventive programs in Mexico. Materials and methods: Cross-sectional nationally representative survey, conducted during 2016 (n=56 877) among those 12-65 years old living in rural, urban and metropolitan dwellings. Results: The prevalence of suicide ideation in the last 12-months was 2.3%, 0.8% of the sample reported a plan and 0.7% reported a suicide attempt. All three outcomes were about two times more common among females and suicide plan and attempt were less common among the elderly (50-65 years old). Suicide attempts were more common in urban than in rural areas. The state of Tabasco showed an increased prevalence of ideation, plan and attempts when compared to national average rates. Conclusions: Public health measures to diminish and treat suicidal behavior are urgently needed all over the country.

Resumen: Objetivo: Dar información actualizada sobre la prevalencia de 12 meses y los factores sociodemográficos asociados para la ideación y el comportamiento suicida (plan e intentos) para fundamentar programas preventivos en México. Material y métodos: Encuesta transversal representativa a nivel nacional, por sexo y grupos de edad, realizada durante 2016 (n = 56 877) entre personas de entre12 y 65 años de edad en zonas rurales, urbanas y metropolitanas. Resultados: La prevalencia de ideación suicida en los últimos 12 meses fue de 2.3%, 0.8% de la muestra informó un plan y 0.7% informó un intento de suicidio. Los tres resultados fueron aproximadamente dos veces más comunes entre las mujeres y el intento de suicidio fue menos común entre los más viejos (50 a 65 años). Los intentos de suicidio fueron más comunes en las zonas urbanas que en las rurales. El estado de Tabasco mostró una mayor prevalencia de ideas, planes e intentos en comparación con las tasas promedio nacionales. Conclusiones: Es urgente y necesario que existan medidas de salud pública para disminuir y tratar el comportamiento suicida en todo el país.

Opioid Crisis Along Mexico's Northern Border: Treatment Needs Mexican Opioid Crisis.

BACKGROUND: Heroin production for external markets and low rates of use in Mexico have had a long history. A recent shift toward an increase in use and related problems calls for the evaluation of treatment needs in order to draw recommendations for policies. METHODS: The objectives were to identify predictors of choice of treatment and barriers to care among persons that had been with no treatment. The study included a convenience sample of 600 face-to-face interviews of people 18 years of age and older and a rapid HIV and HCV tests in three cities on Mexico's Northern Border: Ciudad Juárez, San Luis Río Colorado and Tijuana. The choice of treatment (methadone, other pubic or private treatments with no experience with methadone maintenance and only self-help or religious care), was analyzed though a multiple logistic multimodal regression analysis. Informed consents to be interviewed and for HIC and HIV were signed by interviewers. RESULTS: The majority of persons interviewed were males (89.7%) with an average age of 40. Having emigrated to the United States and a greater length of heroin use predicted seeking methadone treatment versus public or private treatment or informal care. The most important barriers to care were lack of information and stigma. HIC, HIV and other infectious and chronic diseases including depression were often unattended. CONCLUSIONS: There is a need to reform treatment policies in order to cover this w emerging and demanding problem.

Association between attempted suicide and academic performance indicators among middle and high school students in Mexico: results from a national survey.

BACKGROUND: Students' mental health is associated to academic performance. In high income countries, higher students' grades are related to lower odds of suicidal behaviors, but studies on other indicators of academic performance are more limited, specially in middle income countries. METHODS: Data from 28,519 middle and high school students selected with multistage clustered sampling in the Mexican National Survey of Student's Drug Use. Using a self-administered questionnaire, lifetime suicidal attempt and four indicators of academic performance were assessed: age inconsistency with grade level, not being a student in the last year, perceived academic performance and number of failed courses. Multiple logistic regression models were used to control for sociodemographic and school characteristics. RESULTS: The lifetime prevalence of attempted suicide was 3.0% for middle school students and 4.2% for high school students. Among middle school students, statistically adjusted significant associations of suicide attempt with academic performance indicators were: not being a student the year before, worse self-perceived performance and a higher number of failed courses; among high school students, predictors were failed courses and self-perceived academic performance, with ORs of 1.65 and 1.96 for the categories of good and fair/poor respectively, compared to those who reported very good performance. CONCLUSION: Self-perceived academic performance was the main indicator for suicide in both school levels. Suicide prevention efforts in Mexico's schools should include asking students about the perception they have about their own academic performance.

Social factors, weight perception, and weight control practices among adolescents in Mexico.

We evaluated the association of social factors and weight control practices in adolescents, and the mediation of this association by weight perception, in a national survey of students in Mexico ( n = 28,266). We employed multinomial and Poisson regression models and Sobel's test to assess mediation. Students whose mothers had a higher level of education were more likely to perceive themselves as overweight and also to engage in weight control practices. After adjusting for body weight perception, the effect of maternal education on weight control practices remained significant. Mediation tests were significant for boys and non-significant for girls.

Eight-year incidence of psychiatric disorders and service use from adolescence to early adulthood: longitudinal follow-up of the Mexican Adolescent Mental Health Survey.

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.

Barriers to accessing substance abuse treatment in Mexico: national comparative analysis by migration status.

BACKGROUND: We examined Mexican migrants' perceived barriers to entering substance abuse treatment and potential differences by gender. METHODS: This study analyzed a subset of household data collected in Mexico in 2011 via the Encuesta Nacional de Adicciones (National Survey of Addictions). A sample of 1,143 individuals who reported using illicit drugs was analyzed using multivariate negative binomial models to determine direct and moderated relationships of gender, migrant status, and drug dependence with perceived barriers to accessing treatment. RESULTS: Significant findings included disparities in drug dependence by migrant status. Compared with non-migrant men, women who have traveled to the United States was associated with fewer (1.3) barriers to access treatment. Fewer barriers to access care were associated with individuals residing in other regions of the country, compared to those living in Mexico City. CONCLUSIONS: Drug dependence, gender, migration status and regional location are factors associated with access to needed treatment. Implications for health care policy to develop treatment services infrastructure and for future research are discussed in the context of ongoing drug policy reform in Mexico.

The association of chronic adversity with psychiatric disorder and disorder severity in adolescents.

The purpose of this paper is to estimate the impact of chronic adversity on psychopathology in adolescents, taking into account the type of adversity, number of adversities experienced and type of psychiatric disorder, as well as to estimate the impact on severity of the disorder. A total of 3,005 male and female adolescents from the Mexican Adolescent Mental Health Survey aged 12-17 years were interviewed in a stratified multistage general population probability survey. Assessment of 20 DSM-IV disorders, disorder severity and 12 chronic childhood adversities were assessed with the adolescent version of the World Mental Health Composite International Diagnostic Interview (WMH-CIDI-A). Family dysfunction adversities including abuse presented the most consistent associations between chronic adversity and psychopathology and their impact was generally non-specific with regard to the type of disorder. Parental divorce, parental death and economic adversity were not individually associated with psychopathology. Among those with a psychiatric disorder, sexual abuse and family violence were associated with having a seriously impairing disorder. The odds of having a psychiatric disorder and a serious disorder increased with increasing numbers of adversities; however, each additional adversity increased the odds at a decreasing rate. While the study design does not allow for conclusions regarding causality, these findings suggest general pathways from family dysfunction to psychopathology rather than specific associations between particular adversities and particular disorders, and provide further evidence for the importance of family-focused intervention and prevention efforts.

Distribución y determinantes sociodemográficos de la conducta suicida en México / Distribution and socio-demographic determinants of the suicidal behavior in Mexico

Introduction Mexico has seen constant increases in the rate of completed suicide in the last decades, especially among youth. The Mexican population between 1 5-24 years of age is currently the most affected, with 28% of all suicides in 2007. In this context of increasing suicide mortality, the study of suicide-related behaviors, that is, suicidal ideation, plans, gestures and suicide attempts, has special relevance. All of these are immediate precursors to death by suicide and independent risk factors of subsequent suicide attempts and completed suicides. Episodes that do not result in death, can lead to serious, long-term consequences in one's physical health, as well as being an important cause of psychological suffering on the part of the individual and his/her family. Up until now, research in our country has emphasized the prevalence of lifetime suicidal behavior and its associated factors. However, the current (12-month) prevalences are indispensable in order to define the demographic profile and clinical needs, and to build risk profiles for immediate application by the clinics treating these individuals. Objectives To report the prevalence and sociodemographic characteristics of suicide-related behaviors in the past 12 months in a nationally representative sample of respondents from the Encuesta Nacional de Adicciones (ENA) of 2008. Methods Cross-sectional prevalence study which obtained data from a nationally-representative sample of 22 966 individuals, between the ages of 12 and 65, during 2008, who answered the section on suicidal behaviors. The response rate was 77%. Twelve-month prevalences of suicidality are reported according to different sociodemographic and economic factors. Multiple logistic regression models for odds ratios and 95% confidence intervals, corrected for the study design, are reported. Results We found the prevalence of any suicidal ideation to be 8.79% (ranging from 4.2 to 6.2%, depending on the question used), the prevalence of a suicide plan was 1.22%, and 0.79% of the sample reported to attemp suicide within the past 12 months, with the prevalence of suicide attempts that required medical attention being 0.13%. If we use the sample weights to make estimations regarding the 75 million inhabitants of Mexico that the ENA 2008 represents, we estimate that 6 601 210 Mexicans experienced suicidal ideation in the past 12 months, 918 363 Mexicans planned suicide, a total of 593 600 individuals attempted suicide and 99 731 utilized medical services as a consequence of their attempt. We found that women, people who are not married or in a relationship, those with less education, younger age groups and the unemployed have, in general, a higher risk of exhibiting suicidal behavior. Some regions of the country, especially the southeast, were more affected, whereas individuals who live in rural areas consistently reported lower prevalences of the three suicidal behaviors. Conclusion The epidemiology of completed suicide in Mexico has changed within the last decades by a process that has been gradual but constant. The epidemiology of current suicidal behaviors shows that the problem is already at similar levels to other highly affected countries. Mexico needs immediately to dedicate much more efforts to detection, treatment and prevention of these behaviors to avoid further increases in suicidality and its consequences.

Introducción En las últimas décadas, México ha visto incrementos constantes en la tasa de suicidio consumado, especialmente entre la población joven. La población mexicana de entre 15 y 24 años de edad es hoy día de las más afectadas, con 28% de todos los suicidios en 2007. En este contexto de incremento de la mortalidad por suicidio cobra especial relevancia el estudio de las conductas relacionadas con el suicidio, es decir, la ideación suicida, los planes, los gestos y los intentos de suicidio. Todos éstos son precursores inmediatos de la muerte por suicidio y factores de riesgo independientes de intentos subsecuentes de suicidio y de suicidios consumados. Aun cuando estas conductas no lleven a la muerte, pueden acarrear consecuencias graves y de largo alcance para la salud física, y pueden constituir una importante causa de sufrimiento psicológico para el individuo y sus familiares. Hasta ahora, las investigaciones en nuestro país han enfatizado el conocimiento de la prevalencia y los factores asociados con la conducta suicida alguna vez en la vida. Las prevalencias actuales (últimos 12 meses) son, sin embargo, indispensables para definir el perfil demográfico y las necesidades clínicas de atención, y para elaborar perfiles de riesgo de aplicación inmediata para el clínico tratante de estos sujetos. Objetivos En este trabajo reportamos las prevalencias y el perfil sociodemográfico de las conductas relacionadas con el suicidio en los últimos 12 meses en una muestra representativa de la población nacional. Para hacerlo se utilizó la Encuesta Nacional de Adicciones (ENA) del 2008. Métodos Encuesta transversal de prevalencia que obtuvo datos de una muestra representativa de 22 966 miembros de la población nacional, de edades entre los 12 y 65 años, durante el año de 2008, que contestaron la sección de conductas suicidas. La tasa de no respuesta de la ENA 2008 fue de 77%. Se reportan las prevalencias de los eventos relacionados con el suicidio en los últimos 12 meses por diferentes factores sociodemográficos y económicos. Se reportan modelos de regresión logística múltiple con razones de momios y los intervalos de confianza a 95%, que se han corregido por los efectos del diseño de estudio. Resultados Encontramos una prevalencia de cualquier ideación suicida de 8.79% (con variaciones de 4.2 a 6.2%, dependiendo de la pregunta utilizada). La prevalencia de plan suicida fue de 1.22% y 0.79% de la muestra reportó que intentó suicidarse en los últimos 12 meses. La prevalencia de intentos de suicidio que requirieron atención médica fue de 0.13%. Si utilizamos los ponderadores muestrales para hacer estimaciones hacia los 75 millones de habitantes de la República Mexicana que representa la ENA 2008, tenemos que 6 601 210 mexicanos tuvieron ideación suicida en los últimos 12 meses, 918 363 mexicanos planearon suicidarse, un total de 593 600 personas intentaron suicidarse y 99 731 utilizaron servicios médicos como consecuencia de un intento de suicidio. Encontramos que las mujeres, las personas que no están casadas o en unión libre, las de menor escolaridad, los grupos más jóvenes y los subempleados tienen, en general, riesgos más elevados de presentar conducta suicida. Algunas áreas del país, en particular el sureste, se vieron más afectadas, mientras que las personas que viven en áreas rurales reportaron consistentemente menores prevalencias de las tres conductas suicidas. Conclusión La epidemiología del suicidio consumado en México ha cambiado en las últimas décadas, en un proceso paulatino pero constante. La epidemiología de la conducta suicida actual muestra que el problema ha alcanzado ya dimensiones similares a otros países tradicionalmente afectados. México necesita dedicar ya mayores esfuerzos a la detección, tratamiento y prevención de estas conductas para evitar futuros incrementos en la conducta suicida y en sus consecuencias.

Unmet needs for treatment of alcohol and drug use in four cities in Mexico / Necesidades no satisfechas para el tratamiento del uso de drogas y alcohol en cuatro ciudades de México

Introduction Even though heavy alcohol consumption is frequent, alcohol-related consequences are common, and drug use has become more common in this country, we know very little about public health response and the types of treatments available for persons with substance use disorders in Mexico. Current national estimates show that about one in every five persons with alcohol and substance use disorders received treatment in the last 12 months, but to date the rates of treatment for local communities are unknown; these data are needed for policy planning at community level. This study presents data on the treatment for substance use and substance use disorders in three urban areas of Northern Mexico and one state capital in Central Mexico. The Northern region is of particular interest in Mexico because of its proximity to the United States and previous evidence that alcohol and drug use is about twice as common in this region compared with other regions. The city of Queretaro provides a more appropriate comparison for the cities in Northern Mexico than a place as Mexico City, or the national means, due to its level of development, population size, and basic epidemiologic data on drug use. Material and methods The Local Surveys on Addictions 2005 (Encuestas Locales de Adicciones 2005) are part of the Mexican National Survey on Addictions (ENA) series, supported by the Ministry of Health (CONADIC- National Council Against the Addictions), state and local governments, and the National Institute of Psychiatry (INP), and included the cities of Tijuana (Baja California), Ciudad Juarez (Chihuahua), Monterrey (Nuevo Leon) and Queretaro (Queretaro), as part of a continuous effort to monitor use of illicit substances in Mexico. The 12-month prevalence of health and non-health care service use for treatment of substance use was estimated. Correlates of service use, including interference with role impairment, were identified in logistic regression analyses that took into account the complex sample design and weighing process. Results A total of 2,148 completed interviews were obtained for a response rate of 70.5%. About 2.2% of those who used any substance saw any provider in the last 12 months, with the largest prevalence among the health care sector (1.37%), followed closely by the non-health care sector (0.91%). Among the health care sectors, the general medical sector provided more services than mental health specialists. About 11 % of those with any disorder consulted for services, with the health care sector providing many more services than the non-health care sector. The prevalence of use for mental health specialists and the general medical sector is very similar for those with a disorder. The largest prevalence of any service was found in Monterrey (about 15%), while Ciudad Juarez had the lowest (6.6%). Less than 50% of those with an active disorder reported any role impairment, but respondents with high levels of role impairment were more likely to use services. Conclusion We found large unmet needs for substance use services among urban residents of Queretaro and in three major northern cities in Mexico. The two cities that have shown higher rates of substance use in addiction surveys in Mexico (Tijuana and Ciudad Juarez) had the lowest levels of any treatment. We found few predictors of service use among those who used any substance and among those with an active disorder. Among those, respondents with high levels of role impairment were more likely to use services. Treatment for substance use can be effective and is urgently needed if Mexico wants to face the prominent place of alcohol in the burden of disease in the country. The effort to change the current situation of alcohol and drug service utilization, including the low rates of mental health specialists in these cities, is likely to require coordination of research, larger numbers of services, treatment alternatives, and service development.

Introducción Aunque el consumo excesivo de alcohol sea frecuente, las consecuencias de este consumo sean comunes y haya aumentado la disponibilidad de drogas, se sabe poco de las acciones de salud pública y los tipos de tratamiento disponibles para personas con trastornos por el uso de sustancias en México. Estimaciones actuales nacionales muestran que alrededor de una de cada cinco personas con trastornos por el uso de alcohol y drogas recibió tratamiento en los últimos 12 meses. Pese a ello, hasta la fecha no disponemos de estimaciones de las tasas de tratamiento a nivel local, lo que es necesario para la planeación de políticas públicas a nivel comunitario. Este trabajo presenta datos sobre el tratamiento para el uso de sustancias y para los trastornos por el uso de sustancias en tres áreas urbanas del norte de México y una ciudad capital localizada en el centro del país. La región norte es de particular interés por su proximidad con los Estados Unidos y por la evidencia previa de que el alcohol y las drogas es dos veces más común en esta región comparada con otras de la República. Por su nivel de desarrollo, su tamaño poblacional y los datos epidemiológicos básicos que aporta sobre el uso de drogas, la ciudad de Querétaro provee un punto de comparación para las ciudades del norte más apropiado que un lugar como la Ciudad de México o el promedio nacional. Material y métodos Las Encuestas Locales de Adicciones 2005 son parte de la serie de Encuestas Nacionales de Adicciones (ENA), apoyadas por la Secretaría de Salud, el Consejo Nacional Contra las Adicciones (CONADIC), los gobiernos locales y estatales, y el Instituto Nacional de Psiquiatría, e incluyen las ciudades de Tijuana (Baja California), Ciudad Juárez (Chihuahua), Monterrey (Nuevo León) y Querétaro (Querétaro) como parte de un esfuerzo continuo por monitorear el uso de sustancias ilícitas en México. Se estimó la prevalencia en los últimos 12 meses de servicios médicos y no médicos para el tratamiento del uso de sustancias. Los correlatos del uso de servicios, incluida la discapacidad asociada con la interferencia en los roles, se identificaron por medio de regresiones logísticas, mismas que tomaron en consideración el diseño de la muestra y los ponderadores de la encuesta. Resultados Un total de 2148 residentes tuvieron entrevistas completas, para una tasa de respuesta de 70.5%. Solamente 2% de las personas que usaron alcohol o drogas en los últimos 12 meses hicieron uso de algún servicio de tratamiento. La prevalencia más elevada se dio en los servicios de salud (1.37%), seguida de cerca por el sector no médico (0.91%). Entre el sector salud fueron más frecuentes los servicios ofrecidos por el médico general que por los especialistas en salud mental. Alrededor de 11% de aquéllos con algún trastorno por sustancias consultó con los servicios; el sector médico ofreció mucho más servicios que el sector no médico. La prevalencia de uso de servicios de salud mental especializados y la del médico general fueron muy similares para aquellos con un trastorno por sustancias. La prevalencia más elevada de cualquier uso de servicios se dio en la ciudad de Monterrey (alrededor de 15%), mientras que Ciudad Juaréz tuvo la prevalencia más baja (6.6%). Menos de 50% de aquéllos con un trastorno activo mostró algún nivel de discapacidad en el desempeño de roles, pero las personas con mayores niveles de discapacidad tuvieron mayores probabilidades de usar servicios. Conclusiones Encontramos una gran cantidad de necesidades no satisfechas para el tratamiento del uso de sustancias entre residentes de áreas urbanas de cuatro grandes ciudades de México. Las dos ciudades que mostraron las tasas más elevadas de uso de sustancias en otras encuestas de adicciones en México (Tijuana y Ciudad Juárez) mostraron los niveles más bajos de cualquier tratamiento. Encontramos pocos correlatos para el uso de servicios entre aquellos que usaron cualquier sustancia y entre aquellos con un trastorno activo. Entre éstos, los entrevistados con mayores niveles de discapacidad tuvieron mayores probabilidades de usar cualquier servicio. El tratamiento para el uso de sustancias puede ser efectivo y es urgentemente necesario si México quiere enfrentar el lugar prominente que tiene el consumo de alcohol en la carga de la enfermedad en el país. El esfuerzo necesario para cambiar la presente situación del bajo uso de servicios para el tratamiento del consumo de alcohol y drogas, incluidas las bajas tasas de uso de servicios especializados en salud mental, probablemente requiera la coordinación de investigación, mayor número y disponibilidad de servicios, más alternativas de tratamiento y desarrollo de servicios. Son urgentemente necesarias mejorías en la disponibilidad y en los tipos de tratamientos disponibles para los trastornos por uso de sustancias.

Diferencias de sexo en la prevalencia y severidad de trastornos psiquiátricos en adolescentes de la Ciudad de México / Sex differences in the prevalence and severity of psychiatric disorders in Mexico City adolescents

Introduction The first and only nationally representative prevalence estimates of psychiatric disorders in Mexico (the Mexican National Comorbidity Survey) indicate sex differences in the expression of psychopathology and early ages of onset for most disorders, often in the adolescent years. Studies from other countries have shown that sex differences in the pattern of psychopathology vary by life stage, which in part, may be explained by different ages of onset for varying disorders. These studies also suggest that many of the sex differences in the prevalence of disorders emerge during the adolescent years. However, scarce data is available on the epidemiology of adolescent psychopathology in Mexico, and much less regarding possible sex differences in the patterns of prevalence, severity and ages of onset. The purpose of this report, therefore, is to estimate sex differences in the 12-month prevalence and severity of 17 psychiatric disorders (using DSM-IV diagnostic criteria) as well as ages of onset in adolescents from Mexico City metropolitan area. Materials and methods This article provides data from the Mexican Adolescent Mental Health Survey. This survey has a multistage probability design and is representative of adolescents between 12 and 17 years old who reside in the Mexico City metropolitan area. The final sample included 3 005 adolescents selected from a stratified multistage area probability sample. In all strata, the primary sampling units were census count areas cartographically defined and updated in 2000 by the Mexican National Institute of Statistics, Geography and Informatics (INEGI). Two hundred census count areas were selected with probability proportional to size. Secondary sampling units were city blocks, four of which were selected with probability proportional to size from each census count area. All households within these selected city blocks with adolescents aged 12 to 17 were selected. One eligible member from each of these households was randomly selected using the Kish method of random number charts. The response rate of eligible respondents was 71%. The adolescents were interviewed in their homes by trained lay interviewers using the computerized adolescent version of the World Mental Health Composite International Diagnostic Interview (WHM-CIDI-A 3.0). The average length of the interview was two and a half hours. A verbal and written explanation of the study was given to both parents and adolescents. Interviews were administered only to those for whom signed informed consent from a parent and/or legal guardian were obtained as well as the adolescent agreement. Because of the stratified multistage sampling design, data was subsequently weighted to adjust for differential probabilities of selection and non-response. Post-stratification to the total Mexico City Metropolitan Area adolescent population according to the year 2000 Census in target age and sex ranges were also performed. For prevalence estimates, due to this complex sample design and weighting, estimates of standard errors for proportions were obtained by the Taylor series linearization method using the SUDAAN software. Sex differences were evaluated using Wald χ² tests. Statistical significance was based on two-tailed design tests evaluated at the .05 level of significance. Ages of onset for psychiatric disorders were estimated using discrete time survival analyses with person-years as the unit of analysis which in this article are presented as Kaplan-Meier curves. Results The most prevalent individual disorders in both sexes were specific phobia (15.6% for males, 26.1% for females) and social phobia (10.0% for males, 12.4% for females). For females, the most frequent disorders that follow in magnitude after these two types of phobias are, in decreasing order, major depression (7.6%), oppositional defiant disorder (6.9%), agoraphobia without panic (4.7%) and separation anxiety disorder (3.6%). On the other hand, for males, the most frequent disorders after specific and social phobia are oppositional defiant disorder (3.7%), alcohol abuse (3.4%) and conduct disorder (3.3%). Overall, females reported a larger number of disorders and a greater prevalence of any disorder. With regards to disorder severity, mood disorders have the greatest proportion of severe cases and anxiety disorders the smallest proportion of severe cases. While this pattern is found for both males and females, there are sex differences in severity such that females have a greater proportion of severe cases overall (25.5% were severe cases compared to 18.9% for males). The earliest ages of onset were found in anxiety disorders, followed by impulse control disorders, and mood disorders with substance use disorders having the latest ages of onset. The ages of onset for anxiety, mood and substance use disorders are similar between males and females. However, males developed at earlier ages the onset of impulse control disorders than females, and this is due primarily to oppositional defiant disorder rather than to attention deficit hyperactivity disorder or to conduct disorder. Discussion The greater overall prevalence and severity of psychiatric disorders in adolescent females in comparison to adolescent males suggests that adolescence may be a period of greater vulnerability for females. Our findings with regards to a higher prevalence of mood and anxiety disorders in adolescent females in comparison to males are consistent with those reported in the international literature. However, our findings of more impulse control disorders in females than males are inconsistent with most international reports excepting a study of Finnish adolescents in which adolescent girls reported more internalizing and externalizing disorders than their male counterparts. The greater prevalence of impulse control disorders in our study is due to oppositional defiant disorder, not attention deficit hyperactivity or conduct disorder. The lack of sex differences in substance use disorders is consistent with recent findings in Mexican adolescents which show a narrowing of the sex gap difference in substance use. There are both biological and psychosocial theories which may explain the greater vulnerability in adolescent girls such as gender role intensification and socialization during adolescence; a higher exposure to adversity, stress and negative life events; as well as a greater reactivity of the hypothalamic-pituitary-adrenal axis when confronted with stress. Study limitations include the willingness of participants to disclosure sensitive or potentially embarrassing information as well as potential sex differences in willingness. While females reported more disorders and greater severity of disorders overall, sex differences in response style are not likely, since females reported more of many, but not all disorders. A further limitation is the use of trained lay interviewers instead of clinicians. The development and use of fully structured diagnostic instruments such as the CIDI have greatly helped to tackle this limitation in general population surveys and data suggest that diagnoses provided by these fully structured instruments approximate adequately clinical diagnoses. Keeping in mind these limitations, the results of this study are relevant for clinical practice as well as for the epidemiological surveillance of our population to guide service planning and public health policy.

Introducción El presente trabajo proporciona datos de la Encuesta Mexicana de Salud Mental Adolescente y tiene el objetivo de estimar las diferencias por sexo de la prevalencia y la severidad en los últimos 12 meses para 17 trastornos psiquiátricos en adolescentes de la Ciudad de México y área metropolitana así como las edades de inicio de dichos trastornos. Material y métodos El diseño de la muestra fue probabilístico y multietápico, ésta estuvo compuesta por adolescentes entre los 12 y 17 años, residentes del Distrito Federal y área metropolitana. Para ello, se entrevistó a 3005 adolescentes en sus hogares, con una tasa de respuesta de 71 % y se utilizó como instrumento diagnóstico la Entrevista Internacional Diagnóstica Compuesta (WMH-CIDI-A 3.0) aplicada cara a cara, por medio de una computadora portátil, por encuestadores capacitados en los hogares de los participantes. Resultados Los trastornos individuales más frecuentes en ambos sexos fueron las fobias específicas y la fobia social. Para las mujeres, los trastornos más prevalentes en orden decreciente fueron las fobias, la depresión mayor, el trastorno negativista desafiante, la agorafobia sin pánico y la ansiedad por separación. Mientras que en los varones, los trastornos más prevalentes después de las fobias fueron: el trastorno negativista desafiante, el abuso de alcohol y el trastorno disocial. Las mujeres presentaron un mayor número de trastornos y una mayor prevalencia de cualquier trastorno. Los padecimientos con mayor proporción de gravedad fueron los trastornos de ánimo y en menor proporción los trastornos ansiosos. Este patrón fue similar para hombres y mujeres, sin embargo existen diferencias en la proporción de casos graves entre ambos ya que las mujeres tuvieron una mayor proporción de casos de este tipo. Los trastornos que se presentaron en edades de inicio más tempranas fueron los trastornos de ansiedad, seguidos por los trastornos de impulsividad y los trastornos de ánimo. Además los trastornos que se presentaron en edades más tardías fueron los trastornos por uso de sustancias. Las edades de inicio para los trastornos de ansiedad, ánimo y por uso de sustancias son similares entre los sexos, a diferencia de los trastornos de impulsividad en los cuales los hombres tienen edades de inicio más tempranas que las mujeres. Discusión La mayor prevalencia general y severidad de trastornos psiquiátricos en las mujeres comparadas con los varones sugiere que la adolescencia podría ser un periodo de mayor vulnerabilidad para aquellas. Hay teorías biológicas y psicosociales que pretenden explicar la mayor vulnerabilidad de las niñas en la etapa adolescente, entre ellas la teoría de la intensificación del rol de género, la exposición a mayor adversidad y la mayor reactividad del eje hipotálamo-pituitario-adrenal ante el estrés. Los hallazgos de este estudio son relevantes para la práctica clínica así como para la vigilancia epidemiológica en nuestra población ya que sirven para la planificación de servicios y políticas públicas de salud y educación.

Childhood psychosocial stressors and adult onset arthritis: broad spectrum risk factors and allostatic load.

Neural, endocrine, and immune stress mediators are hypothesized to increase risks of diverse chronic diseases, including arthritis. Retrospective data from the World Mental Health Surveys (N=18,309) were employed to assess whether adult onset of arthritis was associated with childhood adversities and early onset psychological disorder. Cox proportional hazard models assessed the association of number of childhood adversities and the presence of early onset psychological disorder with arthritis age of onset. Controlling for age, sex, and early onset mental disorder, relative to persons with no childhood adversities, persons with two adversities had an increased risk of adult onset arthritis (hazard ratio=1.27, 95% CI=1.08, 1.50), while persons with three or more adversities had a higher risk (HR=1.44, CI=1.24, 1.67). Early onset depressive and/or anxiety disorder was associated with an increased risk of adult onset arthritis after controlling for childhood adversities (HR=1.43, CI=1.28, 1.61). Since psychosocial stressors may be broad spectrum risk factors that increase risks of diverse chronic conditions in later life (e.g. arthritis, heart disease, diabetes, asthma, and chronic pain), prospective studies of childhood psychosocial stressors may be most productive if multiple disease outcomes are assessed in the same study. Results from this study provide methodological guidance for future prospective studies of the relationship between childhood psychosocial stressors and subsequent risk of adult onset arthritis.

The Mexican migration to the United States and substance use in northern Mexico.

AIMS: To examine the impact of migration to the United States on substance use and substance use disorders in three urban areas of northern Mexico. DESIGN: Cross-sectional survey of immigration-related experiences and life-time and past-year alcohol and drug use, in a representative sample of respondents aged 12-65 years. SETTING: Interviews were conducted in the cities of Tijuana, Ciudad Juarez and Monterrey during 2005. Respondents were classified into three groups: (i) 'return migrants', (ii) 'relatives of migrants' and (iii) 'others in the general population'. FINDINGS: A total of 1630 completed interviews were obtained for a response rate of 70.5%. 'Return migrants' were more likely to have used alcohol, marijuana or cocaine at least once in their life-time and in the last 12 months, more likely to develop a substance use disorder and more likely to have a 12-month substance use disorder compared with 'others in the general population'. Among 'return migrants', longer length of time in the United States and type of work performed as an immigrant were related to higher prevalence of substance use. Among 'relatives of migrants', migration experiences were not associated with increased prevalence of substance use compared with 'others in the general population'. CONCLUSION: This study found a link between migration to the United States and the transformation of substance use norms and pathology in Mexico. Future research on pre-migration involvement in substance use and data on the timing of events among return migrants is needed. Public health measures are likely to require cross-border coordination of research and service development.

Uso de alcohol, tabaco y drogas en población Mexicana, un estudio de cohortes

resumen está disponible en el texto completo

Summary: Introduction. The availability of drugs and its impact upon our society is undeniably a public concern; the question that remains is to what extent is the population affected. Different sources of information suggest that drug use in Mexico is increasing, especially among the adolescent population. As it has been thirty years since the first epidemiological study of drug use was conducted in Mexico in the 1970's, this is an opportune moment to evaluate the problem by age cohort. This research addresses the question of whether changes in substance use have differentially affected the younger population in terms of the evolution of ages of onset and the socio-demographic determinants of lifetime consumption. Method. This study is a part of the World Mental Health Surveys Initiative from the WHO which was undertaken simultaneously in 30 countries. The target population was taken from uninstitutionalized persons with a fixed residence, between 18 and 65 years of age, and living in urban areas (as defined by more than 2500 inhabitants). The survey is based on a probabilistic, multistage design, stratified by six geographic areas at the national level. Eligible respondents were defined as persons, aged 18 to 65 at the time of the survey, who normally eat, sleep and prepare meals in the household and limited to those that speak Spanish. A total of 5826 individuals were interviewed with a weighted individual response rate of 76.6%. The computer assisted version of the World Mental Health Composite International Diagnostic Interview (WMH-CIDI)was administered. The interview length varied from a minimum of 20 minutes to a maximum of nine hours in four sessions. Fieldwork was carried out by 34 lay interviewers with prior experience in survey data collection and trained by professionals certified by the WHO in the use and training of the CIDI. Standard errors of the estimated prevalences were calculated by the Taylor linearization method using the SUDAAN 2002 statistical package. Kaplan Meir survival curves were generated for the ages of onset using the SAS 2001 software. Logistic regressions were performed to study the demographic correlates of substance use. Estimates of standard errors of odds ratio (ORs) from logistic regression coefficients were also obtained by SUDAAN, and 95% Confidence Intervals (CI) have been adjusted to design effects. Results. Alcohol is the most used substance with less variation by age; 86% of those interviewed report alcohol consumption at some time in their life. The prevalence of alcohol use is followed by tobacco use. Sixty percent of the population report having used tobacco, reaching the greatest proportion of the population in the 45 to 54 year old age group (63%). The non-medical use of drugs, including illicit drugs and legal drugs without a medical prescription, reaches 10% of the population. The illegal use of drugs, including the non-medical use of legal drugs and illicit drugs, in particular marijuana and cocaine, is more frequent among the young and prevalence diminishes with age. Beginning in adolescence, there is a growing prevalence of those reporting the use of these substances, stabilizing shortly before the age of 30. A discrete time survival analysis to estimate the variation in the lifetime prevalence by cohort showed variations in drug use by cohort for all the substances studied, even for alcohol consumption. In all cases, compared to the oldest cohort, the younger cohort are at greater risk of substance use and the greatest risks are concentrated always in the youngest cohort. The cohort differences in probability of substance use is greatest for cocaine, with increases of up to 100 times the risk for those between 18 and 29 years of age. Results of a logistic regression model demonstrate that age continues to be an important risk factor for non-prescription medical substance use, marijuana and cocaine, but not for alcohol and tobacco. For all substances, use is substantially lower for females as well as for the homemaker category of employment. There are no consistent differences for the other demographic variables across the five types of substances. Discussion. This report documents an increase in the risk for substance abuse problems among today's youth, greater than the risk faced by their parents or grandparents at the same age. Use begins increasing during adolescence and stabilizes shortly before the age of 30. There are variations by type of drug such that marijuana has maintained an early age of onset in the different age cohorts while for the use of other substances new cases of onset are found after this age; the substance that shows the greatest proportion of new onset at later ages is cocaine. Even so, the risk of cocaine use is considerably greater in younger cohorts. Survival analysis confirms that compared to older cohorts, the younger have greater risk of substance use and these risks are particularly striking for cocaine use, with as much as 100 times the risk for those between 18 and 29 years of age. These findings coincide with those reported in previous studies in that alcohol and tobacco use surpass by far the use of other substances, with greater use of alcohol than tobacco and both above any other substance. The rate of tobacco and alcohol use is similar throughout the lifespan signifying that this is an endemic problem in our country. On the other hand, findings regarding the use of illegal drugs, in particular marijuana and cocaine, and non-prescription medical drugs show a preponderance of use in the young. These findings reflect the tendencies already reported in other studies. Marijuana use is not new, and has a long tradition throughout the country for which it is not surprising that these results show cases of consumption in all age groups and that the age of onset is similar in all age cohorts, around 17 years of age. However, the growth of marijuana use is reflected by greater lifetime prevalence in the young, three times greater among those now currently 18 to 29 years of age than those of the same age in the 1970's. The use of cocaine before that decade was limited to isolated groups as a socially sophisticated diversion; there is a resurgence in the 1990's when an important increase in use is reflected in all the available surveillance systems. This is reflected in our results by the lower exposure to this drug in the older cohorts. While the risk of marijuana use is 16 times lower in the older cohort than the younger, the risk of cocaine use is 100 times lower in the older cohort than the younger. Our findings suggest that age continues to be an important risk factor for the use of illegal drugs and medical drugs without a prescription, but not for alcohol or tobacco. For all substances, use is lower for females as well as for homemakers indicating that double standards between the genders are still applied. For alcohol there are slightly lower risks for those with lesser educational attainment. This is consistent with other studies which have documented that alcohol consumption increases with buying power which is in turn associated with increased education. These results suggest the need to undertake further research which would allow us a more in depth understanding of the role that social position, including marital status, plays in substance use and abuse. Conclusions. These findings support the hypothesis that the younger generation of today has a greater risk of substance use when compared to their parents when they were young. This point out to the need of increasing actions aimed at reducing the negative impact of this phenomena upon health and society.