Exploring the relationship between admixture and genetic susceptibility to attention deficit hyperactivity disorder in two Latin American cohorts.

Contemporary research on the genomics of Attention Deficit Hyperactivity Disorder (ADHD) often underrepresents admixed populations of diverse genomic ancestries, such as Latin Americans. This study explores the relationship between admixture and genetic associations for ADHD in Colombian and Mexican cohorts. Some 546 participants in two groups, ADHD and Control, were genotyped with Infinium PsychArray®. Global ancestry levels were estimated using overall admixture proportions and principal component analysis, while local ancestry was determined using a method to estimate ancestral components along the genome. Genome-wide association analysis (GWAS) was conducted to identify significant associations. Differences between Colombia and Mexico were evaluated using appropriate statistical tests. 354 Single-nucleotide polymorphisms (SNPs) and Single-nucleotide variants (SNVs) related to some genes and intergenic regions exhibited suggestive significance (p-value < 5*10e-5) in the GWAS. None of the variants revealed genome-wide significance (p-value < 5*10e-8). The study identified a significant relationship between risk SNPs and the European component of admixture, notably observed in the LOC105379109 gene. Despite differences in risk association loci, such as FOXP2, our findings suggest a possible homogeneity in genetic variation's impact on ADHD between Colombian and Mexican populations. Current reference datasets for ADHD predominantly consist of samples with high European ancestry, underscoring the need for further research to enhance the representation of reference populations and improve the identification of ADHD risk traits in Latin Americans.

HIV-Related Stigma and Treatment Adherence Among Gay, Bisexual, and Other Men Who Have Sex with Men Who Use Crystal Meth in the Metropolitan Area of Mexico City.

Internationally, HIV-related stigma and crystal methamphetamine (meth) use have been described as barriers to treatment adherence among gay, bisexual, and other men who have sex with men (gbMSM). Crystal meth use has been increasing among gbMSM in the Metropolitan Area of Mexico City (MAMC). Therefore, this study aimed to determine the association between HIV-related stigma and HIV treatment adherence among gbMSM who use crystal meth in the MAMC. This study was undertaken as part of an exploratory study of crystal meth use in the MAMC. The data were collected from September to December 2021 through an encrypted online survey. Participants (n = 89) were gbMSM adults living with HIV who reported crystal meth use in the past month that were recruited through an online snowball sampling. The online survey included questions about HIV treatment adherence, sexual behaviors, the Alcohol, Smoking, and Substance Involved Screening Test, and the HIV-Related Stigma Mechanisms Scale. Logistic regression analyses assessed the association between HIV-related stigma and HIV treatment adherence. The multivariate logistic regression model showed that, controlling for health insurance [adjusted odds ratio (AOR) = 0.13; 95% confidence intervals (CI)  = 0.02-0.59] and educational level (AOR = 0.16; 95% CI = 0.02-0.88), non-adherence to HIV treatment was independently associated with higher HIV-related stigma (AOR = 1.06; 95% CI = 1.01-1.12). Public health policies must include HIV-related stigma and substance use in treating gbMSM with HIV.

The Impact of Major Earthquakes on Students' Emotional Distress and Internalizing Symptoms, Externalizing Behaviors, and Coping During the Implementation of keepin' it REAL-Mexico.

This article reports on effects of two earthquakes in Mexico on adolescents attending middle school. The earthquakes struck in close succession during the implementation of a school-based prevention program, providing an opportunity to assess emotional distress due to the earthquakes and whether the life skills taught in the program affected how students coped with the natural disaster. The objectives were to (1) evaluate the earthquakes' impact on students' distress; (2) assess if distress is associated with internalizing symptomology and externalizing behaviors; and (3) investigate if students receiving the original and adapted versions of the intervention coped better with the events. A Mexico-US research team culturally adapted keepin' it REAL to address connections between substance use among early adolescents in Mexico and exposure to violence. A random sample of public middle schools from three cities (Mexico City, Guadalajara, and Monterrey), stratified by whether they held morning or afternoon sessions, was selected. A total of 5522 7th grade students from 36 schools participated in the study. Students answered pretest and posttest questionnaires; the latter assessed earthquake-related distress and coping strategies. Earthquake-related distress was associated with all measures of undesired internalizing symptomology and externalizing behaviors. Compared to controls, students in the adapted intervention reported less aggressive and rule-breaking externalizing behavior and less violence perpetration. However, these intervention effects were not moderated by the level of earthquake-related distress, and they were not mediated by positive or negative coping. The findings have implications for prevention intervention research and policy as natural and human-made disasters occur more often.

Feasibility, acceptability, and perceived usefulness of a community-evidence-based harm reduction intervention for sexualized stimulant use among Mexican gay, bisexual, and other men who have sex with men.

BACKGROUND: The use of stimulants and other substances with the purpose of enhancing, maintaining, and prolonging sexual activity is known as sexualized substance use. Also known as chemsex, this pattern of use has been mainly explored in high-income countries. The aim of this article was to assess the feasibility, acceptability, and usefulness of a community- evidence-based harm reduction intervention among Mexican gay, bisexual, and other men who have sex with men (gbMSM) adults who reported sexualized stimulant use in the past 6 months and who were not enrolled in any psychosocial treatment. METHODS: The in-person intervention was designed in partnership with gbMSM who used substances. It consisted of 39 harm reduction strategies before, during, and after episodes of use. The components of the intervention were health and self-care, safety, and psychopharmacology. The intervention was delivered at a university campus, a public recreational space, and an HIV public clinic. Feasibility to deliver the intervention was assessed based on enrolment and completion rates; acceptability through a 28-item, 5-point Likert scale (140 max.) constructed and validated for the Mexican population with good reliability coefficients; usefulness through a 5-point Likert scale ("not useful"-"very useful") for each of the 39 strategies; and potential behavioral change by subtracting the likelihood of implementing each strategy minus the frequency of use of the technique before the intervention. RESULTS: Participants (n = 19; recruitment rate = 35.2%; completion rate = 84.2%) rated the intervention as acceptable with a mean score of 121.6 (SD = 7.5). The highest potential for behavioral change was regarding the use of information about the half-life of stimulants, polysubstance use, and overdose prevention. CONCLUSIONS: This intervention is feasible when provided within public health services where potential participants are already in contact. Harm reduction strategies need to surpass sexually transmitted infections prevention and HIV care and focus on substance use and mental health strategies.

Longitudinal Impact of the COVID-19 Pandemic on Stress and Occupational Well-Being of Mental Health Professionals: An International Study.

BACKGROUND: Increased levels of occupational stress among health professionals during the COVID-19 pandemic have been documented. Few studies have examined the effects of the pandemic on mental health professionals despite the heightened demand for their services. METHOD: A multilingual, longitudinal, global survey was conducted at 3 time points during the pandemic among members of the World Health Organization's Global Clinical Practice Network. A total of 786 Global Clinical Practice Network members from 86 countries responded to surveys assessing occupational distress, well-being, and posttraumatic stress symptoms. RESULTS: On average, respondents' well-being deteriorated across time while their posttraumatic stress symptoms showed a modest improvement. Linear growth models indicated that being female, being younger, providing face-to-face health services to patients with COVID-19, having been a target of COVID-related violence, and living in a low- or middle-income country or a country with a higher COVID-19 death rate conveyed greater risk for poor well-being and higher level of stress symptoms over time. Growth mixed modeling identified trajectories of occupational well-being and stress symptoms. Most mental health professions demonstrated no impact to well-being; maintained moderate, nonclinical levels of stress symptoms; or showed improvements after an initial period of difficulty. However, some participant groups exhibited deteriorating well-being approaching the clinical threshold (25.8%) and persistently high and clinically significant levels of posttraumatic stress symptoms (19.6%) over time. CONCLUSIONS: This study indicates that although most mental health professionals exhibited stable, positive well-being and low stress symptoms during the pandemic, a substantial minority of an already burdened global mental health workforce experienced persistently poor or deteriorating psychological status over the course of the pandemic.

Determinants of effective treatment coverage for posttraumatic stress disorder: findings from the World Mental Health Surveys.

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with significant morbidity, but efficacious pharmacotherapy and psychotherapy are available. Data from the World Mental Health Surveys were used to investigate extent and predictors of treatment coverage for PTSD in high-income countries (HICs) as well as in low- and middle-income countries (LMICs). METHODS: Seventeen surveys were conducted across 15 countries (9 HICs, 6 LMICs) by the World Health Organization (WHO) World Mental Health Surveys. Of 35,012 respondents, 914 met DSM-IV criteria for 12-month PTSD. Components of treatment coverage analyzed were: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) effective treatment coverage. Regression models investigated predictors of treatment coverage. RESULTS: 12-month PTSD prevalence in trauma exposed individuals was 1.49 (S.E., 0.08). A total of 43.0% (S.E., 2.2) received any mental health services, with fewer receiving adequate pharmacotherapy (13.5%), adequate psychotherapy (17.2%), or effective treatment coverage (14.4%), and with all components of treatment coverage lower in LMICs than HICs. In a multivariable model having insurance (OR = 2.31, 95 CI 1.17, 4.57) and severity of symptoms (OR = .35, 95% CI 0.18, 0.70) were predictive of effective treatment coverage. CONCLUSION: There is a clear need to improve pharmacotherapy and psychotherapy coverage for PTSD, particularly in those with mild symptoms, and especially in LMICs. Universal health care insurance can be expected to increase effective treatment coverage and therefore improve outcomes.

Recommendations for Reducing the Risk of Cannabis Use-Related Adverse Psychosis Outcomes: A Public Mental Health-Oriented Evidence Review.

Objective: Cannabis use is increasingly normalized; psychosis is a major adverse health outcome. We reviewed evidence on cannabis use-related risk factors for psychosis outcomes at different stages toward recommendations for risk reduction by individuals involved in cannabis use. Methods: We searched primary databases for pertinent literature/data 2016 onward, principally relying on reviews and high-quality studies which were narratively summarized and quality-graded; recommendations were developed by international expert consensus. Results: Genetic risks, and mental health/substance use problem histories elevate the risks for cannabis-related psychosis. Early age-of-use-onset, frequency-of-use, product composition (i.e., THC potency), use mode and other substance co-use all influence psychosis risks; the protective effects of CBD are uncertain. Continuous cannabis use may adversely affect psychosis-related treatment and medication effects. Risk factor combinations further amplify the odds of adverse psychosis outcomes. Conclusions: Reductions in the identified cannabis-related risks factors-short of abstinence-may decrease risks of related adverse psychosis outcomes, and thereby protect cannabis users' health.

The Feasibility, Acceptability, and Utility of Mantente REAL: the Culturally Adapted Version of keepin' it REAL for Mexico.

A binational team of investigators culturally adapted, implemented, and tested the efficacy in Mexico of keepin' it REAL, a US-designed prevention intervention for youth. This article reports on the social validity of the adapted intervention by assessing its feasibility, acceptability, and utility, as perceived by participating middle school students, teachers/implementers, and school administrators. Middle schools (N = 36) were randomly assigned to (1) the culturally adapted version for Mexico (Mantente REAL), (2) the original intervention from the USA (keepin' it REAL) translated into Spanish, or (3) a control condition (treatment as usual). Adult and child feedback about the adapted and original versions of the intervention indicate that both are feasible to implement in the Mexican context. Implementation fidelity was equally high for both versions of the manualized intervention. Students, however, were more satisfied with the culturally adapted version than with the non-adapted version. They reported gaining more knowledge, finding it more acceptable, applicable, and authentic, and they reported discussing the program with their family and friends more often. The findings support the feasibility of engaging classroom teachers to implement manualized prevention programs in Mexico. These findings also advance prevention science by documenting the importance of cultural adaptation as a means to increase students' identification with and acceptability of efficacious school-based interventions. The article discusses the practice, policy, and future prevention research implications of the findings for Mexico and their potential generalizability to other middle- and lower-income countries.

Perceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report.

BACKGROUND: Treatment guidelines for generalized anxiety disorder (GAD) are based on a relatively small number of randomized controlled trials and do not consider patient-centered perceptions of treatment helpfulness. We investigated the prevalence and predictors of patient-reported treatment helpfulness for DSM-5 GAD and its two main treatment pathways: encounter-level treatment helpfulness and persistence in help-seeking after prior unhelpful treatment. METHODS: Data came from community epidemiologic surveys in 23 countries in the WHO World Mental Health surveys. DSM-5 GAD was assessed with the fully structured WHO Composite International Diagnostic Interview Version 3.0. Respondents with a history of GAD were asked whether they ever received treatment and, if so, whether they ever considered this treatment helpful. Number of professionals seen before obtaining helpful treatment was also assessed. Parallel survival models estimated probability and predictors of a given treatment being perceived as helpful and of persisting in help-seeking after prior unhelpful treatment. RESULTS: The overall prevalence rate of GAD was 4.5%, with lower prevalence in low/middle-income countries (2.8%) than high-income countries (5.3%); 34.6% of respondents with lifetime GAD reported ever obtaining treatment for their GAD, with lower proportions in low/middle-income countries (19.2%) than high-income countries (38.4%); 3) 70% of those who received treatment perceived the treatment to be helpful, with prevalence comparable in low/middle-income countries and high-income countries. Survival analysis suggested that virtually all patients would have obtained helpful treatment if they had persisted in help-seeking with up to 10 professionals. However, we estimated that only 29.7% of patients would have persisted that long. Obtaining helpful treatment at the person-level was associated with treatment type, comorbid panic/agoraphobia, and childhood adversities, but most of these predictors were important because they predicted persistence rather than encounter-level treatment helpfulness. CONCLUSIONS: The majority of individuals with GAD do not receive treatment. Most of those who receive treatment regard it as helpful, but receiving helpful treatment typically requires persistence in help-seeking. Future research should focus on ensuring that helpfulness is included as part of the evaluation. Clinicians need to emphasize the importance of persistence to patients beginning treatment.

(Internet) Gaming Disorder in DSM-5 and ICD-11: A Case of the Glass Half Empty or Half Full: (Internet) Le trouble du jeu dans le DSM-5 et la CIM-11: Un cas de verre à moitié vide et à moitié plein.

BACKGROUND: Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included in 2013 Internet gaming disorder (IGD) as a condition for further study, and in 2018, the World Health Organization included gaming disorder (GD) as a mental disorder in the International Classification of Disease (ICD-11). We aim to compare disorders of gaming in both diagnostic systems using a sample of young adults in Mexico. METHODS: Self-administered survey to estimate the prevalence of DSM-5 IGD and ICD-11 GD in 5 Mexican universities; 7,022 first-year students who participated in the University Project for Healthy Students, part of the World Health Organization World Mental Health International College Student Initiative. Cross-tabulation, logistic regression, and item response theory were used to inform on 12- month prevalence of DSM-5 IGD and ICD-11 GD, without and with impairment. RESULTS: The 12-month prevalence of DSM-5 IGD was 5.2% (95% CI, 4.7 to 5.8), almost twice as high as the prevalence using the ICD-11 GD criteria (2.7%; 95% CI, 2.4 to 3.1), and while adding an impairment requirement diminishes both estimates, prevalence remains larger in DSM-5. We found that DSM-5 cases detected and undetected by ICD-11 criteria were similar in demographics, comorbid mental disorders, service use, and impairment variables with the exception that cases detected by ICD-11 had a larger number of symptoms and were more likely to have probable drug dependence than undetected DSM-5 cases. CONCLUSION: DSM-5 cases detected by ICD-11 are mostly similar to cases undetected by ICD-11. By using ICD-11 instead of DSM-5, we may be leaving (similarly) affected people underserved. It is unlikely that purely epidemiological studies can solve this discrepancy and clinical validity studies maybe needed.

Prevalence of 12-month mental and substance use disorders in sexual minority college students in Mexico.

PURPOSE: Mental 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. METHOD: The 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. RESULTS: Compared 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. CONCLUSION: These 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.

Keepin' It REAL-Mantente REAL in Mexico: a Cluster Randomized Controlled Trial of a Culturally Adapted Substance Use Prevention Curriculum for Early Adolescents.

This study assesses the efficacy of a version of the keepin' it REAL (kiREAL) substance use prevention curriculum for middle school students that was culturally adapted for Mexico, renamed Mantente REAL (MREAL), and tested in a cluster randomized controlled trial in Mexico's three largest cities. Student participants were in 7th grade in public middle schools (N = 5523, 49% female, mean age = 11.9). A representative sample of 12 schools from each city, stratified by whether they held morning or afternoon sessions, was randomized to three conditions: culturally adapted MREAL, original kiREAL translated into Spanish, or a treatment-as-usual control group. Regular classroom teachers were trained to deliver the adapted MREAL or the kiREAL manualized curricula. Students with active parental consent completed pretest and post-test questionnaires, 7-8 months apart, at the beginning and end of the 2017-2018 academic year. We assessed the MREAL intervention, relative to kiREAL and controls, with general linear models adjusted for baseline, attrition (24%), non-normal distributions, stratification by city, and school-level clustering. Among students already using the substance more often at pretest, MREAL students had relatively more desirable outcomes, compared to kiREAL and/or to controls, in recent use of alcohol, cigarettes, "hard drugs," heavy episodic drinking, and intoxication. MREAL students reported relatively less violence victimization and perpetration of bullying and relatively more use of three of the intervention's REAL drug resistance strategies (Explain, Avoid, Leave). The adapted version of kiREAL for Mexico showed numerous desired outcomes in areas deliberately targeted in the cultural adaptation. Full protocol can be accessed through Clinical Trials.gov. ID: NCT03233386, "'Keepin' It REAL in Mexico: An adaptation and multisite RCT".

Out-of-pocket and catastrophic expenses in households of patients with schizophrenia lacking social security

OBJECTIVE: To estimate the magnitude of out-of-pocket (OOP) and catastrophic health expenses as well as impoverishment experienced by households of schizophrenia patients lacking social security coverage. MATERIALS AND METHODS: We conducted a cross-sectional study of 96 individuals treated in outpatient consultation between February and December 2018 in a psychiatric hospital. RESULTS: All households sustained OOP health expenses; the median was 510 USD (95%CI: 456-628). The OOP expenses represented 28 and 4% of the capacity to pay in poor and rich households, respectively. 16% of households incurred catastrophic expenses and 6.6% have impoverishment for health reasons. CONCLUSIONS: Our results illustrate that pocket expenses and catastrophic expenses in patients with schizophrenia are higher than those reported for the general population. Therefore, it is necessary to rethink the financial protection policies aimed at patients with schizophrenia and their households.

Identifying Risk Factors for Self-reported Mental Health Problems in Psychiatry Trainees and Psychiatrists in Mexico.

OBJECTIVE: The objective was to determine and compare demographic features, professional activities and adversities, physical health conditions, and self-care behaviors related to the most frequently self-reported mental health problems among psychiatrists and psychiatry trainees. METHODS: A cross-sectional, retrospective, comparative study was conducted on a total of 330 (48.2%) psychiatry trainees and 355 (51.8%) psychiatrists from Mexico through an online survey. Demographic features, professional activities and adversities, physical and mental health problems, self-care behaviors, and social support were examined. Comparative analyses and multiple logistic regression models were performed. RESULTS: Major depression, anxiety, and burnout were the most common mental health problems reported with a higher frequency of anxiety disorders in psychiatry trainees. Being a woman, having a physical health problem, and lack of restful sleep were the main risk factors in both groups. Consultation in the government sector and having patients with severe suicidal ideation affected more psychiatry trainees. Perceived discrimination and inadequate eating schedules were risk factors for mental health problems for psychiatrists. CONCLUSION: Psychiatry trainees constitute a vulnerable group for anxiety disorders. Particular attention should be paid to how students cope with the training experience to determine whether additional support is required. These professionals face major stressors leading to a high prevalence of depression, burnout, and anxiety. Encouraging psychiatrists to have better health habits is a step in the right direction, which must be accompanied by tangible organizational avenues to do so and creating a culture that truly promotes self-care.

Perceived helpfulness of treatment for posttraumatic stress disorder: Findings from the World Mental Health Surveys.

BACKGROUND: Perceived helpfulness of treatment is an important healthcare quality indicator in the era of patient-centered care. We examine probability and predictors of two key components of this indicator for posttraumatic stress disorder (PTSD). METHODS: Data come from World Mental Health surveys in 16 countries. Respondents who ever sought PTSD treatment (n = 779) were asked if treatment was ever helpful and, if so, the number of professionals they had to see to obtain helpful treatment. Patients whose treatment was never helpful were asked how many professionals they saw. Parallel survival models were estimated for obtaining helpful treatment in a specific encounter and persisting in help-seeking after earlier unhelpful encounters. RESULTS: Fifty seven percent of patients eventually received helpful treatment, but survival analysis suggests that it would have been 85.7% if all patients had persisted in help-seeking with up to six professionals after earlier unhelpful treatment. Survival analysis suggests that only 23.6% of patients would persist to that extent. Odds of ever receiving helpful treatment were positively associated with receiving treatment from a mental health professional, short delays in initiating help-seeking after onset, absence of prior comorbid anxiety disorders and childhood adversities, and initiating treatment before 2000. Some of these variables predicted helpfulness of specific treatment encounters and others predicted persistence after earlier unhelpful encounters. CONCLUSIONS: The great majority of patients with PTSD would receive treatment they considered helpful if they persisted in help-seeking after initial unhelpful encounters, but most patients whose initial treatment is unhelpful give up before receiving helpful treatment.

[Mental health care needs and use of services in Mexican population with serious mental disorders]. / Necesidades de atención en salud mental y uso de servicios en población mexicana con trastornos mentales graves.

OBJECTIVE: To analyze the mental health care needs of the serious mental disorders (SMD) and factors associated with the use of services in Mexico. MATERIALS AND METHODS: A cross-sectional analytical study was conducted in two phases, the first with a national database of available services and its utilization; the second, a sample of medical records of a psychi- atric hospital. RESULTS: Schizophrenia is the most prevalent MDS; more than 50% of those hospitalized were male, with an average age of 37 years. The use of services was associated with age (ß=1.062, p=.000), family income (ß=1.000, p=.000) and no laboral occupation (ß=3.407, p=.000). The population with schizophrenia is four times more likely to require to be exempt from payment (ß=4.158, p=.000). CONCLUSIONS: The population with SMD as schizophrenia is more vulnerable due to the associated functional and social disability and it requires specific heath interventions and a financial protection policy adapted to their mental health care needs.

OBJETIVO: Analizar las demandas de atención de los trastornos mentales graves (TMG) y factores asociados con la utilización de servicios en México. MATERIAL Y MÉTODOS: Se llevó a cabo un estudio analítico transversal en dos fases: la primera con una base de datos nacional de servicios disponibles y su utilización; la segunda, una muestra de registros médicos de un hospital psiquiátrico. RESULTADOS: La esquizofrenia es el TMG más prevalente; más de 50% de hospitalizados fueron hombres, con edad promedio 37 años. La utilización de servicios estuvo asociada con la edad (ß=1.062; p=.000), ingreso familiar (ß=1.000, p=.000) y no tener ocupación (ß=3.407; p=.000). La población con esquizofrenia tiene cuatro veces más la probabilidad de requerir estar exenta de pago (ß=4.158; p=.000). CONCLUSIONES: La población con TMG es más vulnerable por la discapacidad funcional y social asociada; requiere de intervenciones específicas de salud acompañadas de una política de protección financiera adaptada a sus necesidades de atención.

Where Is the Opioid Use Epidemic in Mexico? A Cautionary Tale for Policymakers South of the US-Mexico Border.

In North America, opioid use and its harms have increased in the United States and Canada over the past 2 decades. However, Mexico has yet to document patterns suggesting a higher level of opioid use or attendant harms.Historically, Mexico has been a country with low-level use of opioids, although heroin use has been documented. Low-level opioid use is likely attributable to structural, cultural, and individual factors. However, a range of dynamic factors may be converging to increase the use of opioids: legislative changes to opioid prescribing, national health insurance coverage of opioids, pressure from the pharmaceutical industry, changing demographics and disease burden, forced migration and its trauma, and an increase in the production and trafficking of heroin. In addition, harm-reduction services are scarce.Mexico may transition from a country of low opioid use to high opioid use but has the opportunity to respond effectively through a combination of targeted public health surveillance of high-risk groups, preparation of appropriate infrastructure to support evidence-based treatment, and interventions and policies to avoid a widespread opioid use epidemic.

Legal and Policy Implications in Mexico of Changes in ICD-11 Paraphilic Disorders.

INTRODUCTION: The World Health Organization (WHO) has made substantial changes to the classification of paraphilic disorders for the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11), recently approved by the World Health Assembly. The most important is to limit paraphilic disorders primarily to persistent and intense patterns of atypical sexual arousal involving non-consenting individuals, manifested through persistent sexual thoughts, fantasies, urges, or behaviors, that have resulted in action or significant distress. AIM: To analyze the legal, regulatory, and policy implications of the changes in the ICD-11 classification of paraphilic disorders for forensic practice, health systems, adjudication of sex offenders, and the provision of treatment in Mexico. METHODS: An expert Mexican advisory group was appointed to conduct this evaluation following an assessment guide provided by the WHO. MAIN OUTCOME MEASURES: The WHO assessment guide covered (i) laws related to sexual behaviors; (ii) the relationship between legal and clinical issues for non-forensic health professionals; (iii) implications of mental disorder classification for forensic practice; (iv) other implications of ICD-11 paraphilic disorders proposals; and (v) contextual issues. RESULTS: A variety of factors in Mexico make it highly unlikely that appropriate, evidence-based treatments for paraphilic disorders will be provided to those who need them, even if they seek treatment voluntarily and have not committed a crime. Mexican law focuses on the punishment of specific sexual behaviors rather than on underlying disorders. A paraphilic disorder would not be considered sufficient grounds for exemption from criminal responsibility. The application and scope of mental health evaluations in Mexican legal proceedings are quite limited, and individuals who commit sexual crimes almost never undergo forensic evaluations to establish the presence of paraphilic disorders. Psychiatric services may be mandated for sex offenders in highly specific circumstances but cannot exceed the duration of the criminal sentence. CLINICAL IMPLICATIONS: Evaluation and treatment guidelines should be developed based on international evidence and standards and promulgated for use with individuals with paraphilic disorders in forensic and non-forensic poopulations. The much greater specificity and operationalization of the ICD-11 guidelines as compared with the ICD-10 guidelines provide a better basis for identification and case formulation. STRENGTHS & LIMITATIONS: Major strengths of this analyses were that it was conducted to facilitate international comparability across several participating countries and the fact that it was conducted by a diverse multidisciplinary group representing various relevant legal, forensic and and clinical sectors. A limitation was that it was only possible to examine relevant federal laws and those of Mexico City rather than those of all 32 Mexican states. CONCLUSION: The descriptions of paraphilic disorders in the ICD-11 could support substantial improvements in the treatment of individuals with paraphilic disorders and the adjudication of sex offenders in Mexico, but specific changes in Mexican law would be required. Martínez-López JNI, Robles R, Fresán A, et al. Legal and Policy Implications in Mexico of Changes in ICD-11 Paraphilic Disorders. J Sex Med 2019;16:1623-1637.

Multidimensional Patterns of Sexual Risk Behavior and Psychiatric Disorders in Men with Substance Use Disorders.

Previous evidence links substance use disorders (SUD) to STI/HIV risk and suggests that comorbid psychiatric disorders increase the probability to engage in sexual risk behaviors. This study had two aims: (1) to identify subgroups based on sexual risk behavior using a person-centered approach in a sample of substance users and (2) to measure the association of psychiatric and SUD with subgroup membership. We assessed 402 male adults with SUD, reporting sexual intercourse in the previous 12 months using the HIV-Risk Behavior Scale and the Mini International Neuropsychiatric Interview. Latent class analysis was performed to determine multidimensional patterns of sexual risk behaviors and multinomial logistic regression was utilized to associate classes with disorders. The three-class model showed the best fit, and the classes were labeled: Relationship-Based (31.34% of the sample), Condom-Based (39.55%), and Multiple Risks (29.10%). Controlling for age and marital status, major depressive disorders, antisocial personality disorder, and any psychiatric disorder were associated with the Multiple Risks class. Results stress the importance of developing a personalized assessment and counseling for sexual risk behaviors in individuals with SUD, particularly when they endorse criteria for comorbid psychiatric disorders. Future studies should focus on evaluating differential response to preventive interventions.

The relationship between neighborhood-level socioeconomic characteristics and individual mental disorders in five cities in Latin America: multilevel models from the World Mental Health Surveys.

PURPOSE: Our understanding of community-level predictors of individual mental disorders in large urban areas of lower income countries is limited. In particular, the proportion of migrant, unemployed, and poorly educated residents in neighborhoods of these urban areas may characterize group contexts and shape residents' health. METHODS: Cross-sectional household interviews of 7251 adults were completed across 83 neighborhoods of Buenos Aires, Argentina; Medellín, Colombia; São Paulo, Brazil; Lima, Peru; and Mexico City, Mexico as part of the World Mental Health Survey Initiative. Past-year internalizing and externalizing mental disorders were assessed, and multilevel models were used. RESULTS: Living in neighborhoods with either an above-average or below-average proportion of migrants and highly educated residents was associated with lower odds of any internalizing disorder (for proportion migrants: OR 0.75, 95% CI 0.62-0.91 for the bottom tertile and OR 0.79, 95% CI 0.67-0.94 for the top tertile compared to the middle tertile; for proportion highly educated: OR 0.76, 95% CI 0.64-0.90 for the bottom tertile and OR 0.58, 95% CI 0.37-0.90 for the top tertile compared to the middle tertile). Living in neighborhoods with an above-average proportion of unemployed individuals was associated with higher odds of having any internalizing disorder (OR 1.49, 95% CI 1.14-1.95 for the top tertile compared to the middle tertile). The proportion of highly educated residents was associated with lower odds of externalizing disorder (OR 0.54, 95% CI 0.31-0.93 for the top tertile compared to the middle tertile). CONCLUSIONS: The associations of neighborhood-level migration, unemployment, and education with individual-level odds of mental disorders highlight the importance of community context for understanding the burden of mental disorders among residents of rapidly urbanizing global settings.