TYPE Original Research PUBLISHED 16 February 2023 DOI 10.3389/fpsyt.2023.1095222 Psychosocial factors associated OPEN ACCESS with the risk of developing psychosis in a Mexican general EDITED BY Marta Santarén, Universidad Internacional De La Rioja, Spain REVIEWED BY population sample Teresa Sanchez-Gutierrez, Universidad Internacional De La Rioja, Spain Tecelli Domínguez-Martínez 1*, Tamara Sheinbaum 2, Ana Fresán 3, Francesco Monaco, Lourdes Nieto 1, Steven R. López 4, Rebeca Robles 1, Ma Azienda Sanitaria Locale Salerno, Italy del Carmen Lara 5, Camilo de la Fuente-Sandoval 6, *CORRESPONDENCE Neus Barrantes-Vidal 7,8,9, Ricardo Saracco 3, Tecelli Domínguez-Martínez tecelli.dominguez@gmail.com Karina Franco-Paredes 10, Felipe Díaz-Reséndiz 10 and SPECIALTY SECTION Mauricio Rosel 11 This article was submitted to 1 Centro de Investigación en Salud Mental Global, Instituto Nacional de Psiquiatría “Ramón de la Fuente Psychopathology, Muñiz”-UNAM, Mexico City, Mexico, 2 Dirección de Investigaciones Epidemiológicas y Psicosociales, a section of the journal Instituto Nacional de Psiquiatría “Ramón de la Fuente Muñiz”, Mexico City, Mexico, 3 Subdirección de Frontiers in Psychiatry Investigaciones Clínicas, Instituto Nacional de Psiquiatría “Ramón de la Fuente Muñiz”, Mexico City, Mexico, RECEIVED 10 November 2022 4 Department of Psychology, University of Southern California, Los Angeles, CA, United States, 5 Facultad de ACCEPTED 25 January 2023 Medicina, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico, 6 Laboratorio de Psiquiatría PUBLISHED 16 February 2023 Experimental, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico, 7 Departament de Psicologia Clínica i de la Salut, Universitat Autònoma de Barcelona, Barcelona, Spain, 8 Sant Pere Claver - CITATION Fundació Sanitària, Barcelona, Spain, 9 Centre for Biomedical Research Network on Mental Health Domínguez-Martínez T, Sheinbaum T, Fresán A, (CIBERSAM), Instituto de Salud Carlos III, Barcelona, Spain, 10 Universidad de Guadalajara-Centro Nieto L, López SR, Robles R, Lara MC, de la Universitario del Sur, Guadalajara, Mexico, 11 Clínica de Esquizofrenia, Instituto Nacional de Psiquiatría Fuente-Sandoval C, Barrantes-Vidal N, “Ramón de la Fuente Muñiz”, Mexico City, Mexico Saracco R, Franco-Paredes K, Díaz-Reséndiz F and Rosel M (2023) Psychosocial factors associated with the risk of developing psychosis in a Mexican general Epidemiological evidence has linked an array of sociodemographic and psychosocial population sample. factors with an increased risk of developing psychosis. However, research in samples Front. Psychiatry 14:1095222. from low- and middle-income countries is still scarce. This study used a Mexican doi: 10.3389/fpsyt.2023.1095222 sample to explore (i) sociodemographic and psychosocial differences between COPYRIGHT individuals with and without a positive screen for Clinical High-Risk for psychosis (CHR), © 2023 Domínguez-Martínez, Sheinbaum, Fresán, Nieto, López, Robles, Lara, de la and (ii) sociodemographic and psychosocial factors associated with screening positive Fuente-Sandoval, Barrantes-Vidal, Saracco, for CHR. The sample consisted of 822 individuals from the general population who Franco-Paredes, Díaz-Reséndiz and Rosel. This completed an online survey. Of the participants, 17.3% (n=142) met the CHR screening is an open-access article distributed under the terms of the Creative Commons Attribution criteria. Comparisons between those who screened positive (CHR-positive group) and License (CC BY). The use, distribution or those who did not (Non-CHR group) showed that participants in the CHR-positive reproduction in other forums is permitted, group were younger, had a lower educational level, and reported more mental health provided the original author(s) and the copyright owner(s) are credited and that the problems than the Non-CHR group. Furthermore, relative to the Non-CHR group, the original publication in this journal is cited, in CHR-positive group had a greater prevalence of medium/high risk associated with accordance with accepted academic practice. cannabis use, a higher prevalence of adverse experiences (bullying, intimate partner No use, distribution or reproduction is permitted which does not comply with these violence, and experiencing a violent or unexpected death of a relative or friend), as terms. well as higher levels of childhood maltreatment, poorer family functioning, and more distress associated with the COVID-19 pandemic. Groups did not differ in sex, marital/relationship status, occupation, and socio-economic status. Finally, when examined in multivariate analyses, the variables associated with screening positive for CHR were: having an unhealthy family functioning (OR=2.75, 95%CI 1.69–4.46), a higher risk associated with cannabis use (OR=2.75, 95%CI 1.63–4.64), a lower level of education (OR=1.55, 95%CI 1.003–2.54), having experienced a major natural disaster (OR=1.94, 95%CI 1.18–3.16), having experienced a violent or unexpected death of a relative or friend (OR=1.85, 95%CI 1.22–2.81), higher levels of childhood emotional abuse (OR=1.88, 95%CI 1.09–3.25), physical neglect (OR=1.68, 95%CI 1.08–2.61), and physical abuse (OR=1.66, 95%CI 1.05–2.61), and higher COVID-related distress (OR=1.10, 95%CI 1.01–1.20). An older age was a protective factor for screening positive Frontiers in Psychiatry 01 frontiersin.org Domínguez-Martínez et al. 10.3389/fpsyt.2023.1095222 for CHR (OR=0.96, 95%CI 0.92–0.99). Overall, the findings highlight the importance of examining potential psychosocial contributors to psychosis vulnerability across different sociocultural contexts to delineate risk and protective processes relevant to specific populations and better target preventive intervention efforts. KEYWORDS clinical high-risk, prodrome, psychosis, family functioning, cannabis use, life adversities, childhood trauma and adversity, early detection and prevention 1. Introduction Psychotic disorders are considered polygenic and multifactorial (12), likely resulting from the synergistic co-participation of genetic and Psychotic spectrum disorders are complex syndromes characterized environmental factors (22). Although the genetic aspects of these disorders by a disconnection from reality and the presence of varied symptoms have received considerable attention (23), there is growing interest in the such as delusions, hallucinations, distortion of the thought process, contribution of sociodemographic and psychosocial factors to the etiology disorganized thinking and/or motor behavior, negative symptoms (i.e., and course of psychosis (24–26). To date, epidemiological evidence has affective blunting, alogia, asociality, anhedonia, and avolition), cognitive linked an array of such factors with an increased risk for psychosis. These deficits, and functional impairment (1, 2). These disorders commonly include male gender, age between 15 and 35 years, migrant or ethnic appear during the transition period between adolescence and adulthood minority status, urbanicity, difficult socioeconomic conditions or and cause impairments across multiple life domains, generating household poverty, and cannabis use (12, 19, 27–33). In addition, strong significant personal, social, health, and economic costs (3). evidence demonstrates that a range of childhood adversities and traumatic Research has demonstrated that psychotic-like experiences are life events are pluripotent risk factors associated with the development of common in the general population, and psychotic symptoms are not psychosis in adolescence and adulthood (34–42). The most prominent exclusive to psychotic disorders but are transdiagnostic and may adversity experiences associated with psychosis risk include parental be present in different mental disorders (4). Studies on the prevalence separation or loss (2, 12, 41, 43–45), child maltreatment (sexual, physical, of psychotic-like experiences (i.e., milder forms of positive psychotic and emotional abuse, and physical and emotional neglect), and peer symptoms in the absence of a psychotic disorder) have produced mixed victimization or bullying (41, 46–52). Overall, the evidence appears to findings that vary according to place and ethnicity (5). These studies be especially robust for interpersonal forms of adversity, whereas that for have generally found a prevalence of between 5 and 10% in the general non-interpersonal traumatic events (such as accidents or natural disasters) population (6, 7) and in adolescents (8). Furthermore, recent studies on is more limited and inconsistent (53). the impact of the COVID-19 pandemic and lockdown have reported an The family environment is another important factor in psychosocial increased prevalence of psychotic-like experiences in adolescent and research on psychosis (54). Although characteristics of the family general population samples (9–11). Although psychotic-like experiences environment have generally received more attention as predictors of tend to be transitory in around 80% of those who experience them, relapse (55, 56), there is also evidence suggesting a contribution to the approximately 20% develop persistent psychotic-like experiences, and risk of psychosis (57–59). For instance, family criticism has been 7% a psychotic disorder (4, 5). associated with psychosis proneness, particularly in developing The onset of psychosis is usually preceded by premorbid countries (60), and with the worsening of symptoms at the CHR stage developmental alterations and can start with a prodromal phase (61). On the other hand, although less studied, positive characteristics characterized at first by non-specific symptoms, and then by subthreshold of the family environment, such as family warmth, have been identified positive, negative, affective, and behavioral symptoms (12). Over the last as protective factors (62–64). decades, increasing research has focused on the early detection and The identification of sociodemographic and psychosocial factors intervention in psychosis paradigm, based on the possibility of that contribute to CHR states for psychosis across different populations identifying adolescents and young adults at the preclinical or subclinical and cultural contexts can broaden our understanding of risk and phase, before the onset of the first episode of psychosis. These individuals protective processes (65). Such research is crucial to inform the design are considered to be at imminent risk for developing psychotic disorders, of preventive strategies that can target modifiable factors (12, 66, 67) at also known as “Clinical High Risk” (CHR), “Ultra-High Risk” (UHR), or a moment free of the confounding effects associated with clinical status, At-Risk Mental States for Psychosis (13, 14). The CHR stage of psychosis such as medication, chronicity, hospitalization, and social is typically defined by the presence of either attenuated (subclinical) or marginalization (68). Currently, research in this field is scarce in low- transient positive psychotic symptoms (i.e., lasting no more than a week, and middle-income countries (69). As such, further work is needed to with spontaneous full recovery), along with a significant decrease in identify factors associated with psychosis risk in different contexts than psychosocial functioning in the last year (15–17). A recent systematic those of high-income countries (mainly European countries, Australia, review and meta-analysis indicated a prevalence of 1.7% of CHR states and the United States), where most studies have been conducted with in the general population of adolescents and young adults, and 19.2% in samples that do not represent the heterogeneity of the world’s those entering mental health services for the first time (18). Although it population (70). has been suggested that the prevalence of CHR may vary according to Mexico is one such country where scant research in this field has gender (19), age (20), and geographical location (21), the impact of these been conducted and where more regionally adapted knowledge is factors has not been clearly established (18). required to guide the development of specialized early psychosis Frontiers in Psychiatry 02 frontiersin.org Domínguez-Martínez et al. 10.3389/fpsyt.2023.1095222 services that are almost nonexistent (71). Furthermore, the Mexican about prior history of mental health difficulties and the type of population has experienced a range of adverse conditions, such as difficulty experienced. extreme poverty, social inequality, insecurity, and widespread violence. In addition, the population has been continuously impacted 2.2.2. CHR screening by natural disasters, such as earthquakes and floods. The above The screening of CHR for psychosis status was based on two circumstances, taken together with the stress and disruptions measures. The first was the 21-item Prodromal Questionnaire-Brief associated with the COVID-19 pandemic, add further support to the (PQ-B) (72, 73), a reliable and widely-used psychosis-risk screening relevance of examining sociodemographic and psychosocial factors instrument (74). Each PQ-B item is rated dichotomously (yes/no), and associated with the risk for psychosis in this population. Therefore, endorsed items are further rated on a 5-point distress scale. Following this study used a Mexican general population sample to explore (i) Fonseca-Pedrero et al. (72), we used the following PQ-B cut-off criteria: sociodemographic and psychosocial differences between individuals more than 6 positively endorsed items and a score equal to or above 29 with and without a positive screen for CHR, and (ii) on the distress scale. The second measure was the Social Functioning sociodemographic and psychosocial factors associated with Questionnaire (SFQ) (75), which assesses functioning across diverse life screening positive for CHR. domains, such as social contacts, work and home tasks, and leisure activities. Our use of this measure is in keeping with prior recommendations of considering low functioning as a criterion to 2. Materials and methods identify CHR individuals (17, 76). The SFQ consists of 8 items rated on a 4-point scale, with higher scores indicating worse functioning. SFQ 2.1. Participants and procedure sum scores of 10 or higher are indicative of poor social functioning (75). Accordingly, participants were assigned to the CHR-positive group if The data were collected as part of an ongoing research project they met the established cut-off scores on both the PQ-B and SFQ. examining risk and protective factors for subclinical psychopathology in the Mexican general population. The current sample was recruited 2.2.3. Childhood maltreatment between March and July 2022 with individuals who voluntarily agreed The 28-item Childhood Trauma Questionnaire (CTQ) (77, 78) was ® to take part in an online survey administered via Qualtrics software. used to assess sexual abuse, physical abuse, emotional abuse, emotional For the present study, inclusion criteria were being born and currently neglect, and physical neglect. CTQ items are answered on a 5-point scale residing in Mexico and being between 15 and 45 years old. Given the ranging from “never true” to “very often true” and are summed to obtain study’s focus on identifying predictors of CHR, exclusion criteria were a score for each type of maltreatment. Higher scores indicate greater self-reporting a psychotic spectrum disorder or a psychosis- levels of maltreatment. Consistent with current recommendations in the related hospitalization. psychosis literature (79), we used the thresholds outlined by Walker The invitation to participate in the survey was distributed to the et al. (80) to dichotomize each type of maltreatment according to the general population via personal and institutional (health and educational presence of clinically significant levels of exposure. These thresholds are institutions) social media channels. All participants aged 18 and older as follows: a score of 15 or higher for emotional neglect, 10 or higher for provided informed consent. Youth were additionally invited to emotional abuse, and 8 or higher for sexual abuse, physical abuse, and voluntarily participate through their high schools. School authorities physical neglect. sent information about the purposes of the study to parents or guardians via institutional e-mail and asked them to provide informed consent for 2.2.4. Other adverse experiences their children’s participation. The survey was administered to minors Additional items were included to broaden the coverage of lifetime authorized by their parents/guardians to participate and who provided traumatic experiences. Specifically, we used 3 items adapted from the their informed assent. Participants did not receive compensation for Brief Trauma Questionnaire (BTQ) (81) and 2 items adapted from the completing the survey. The study was approved by the Research Ethics Questionnaire of Stressful Life Events (QSLE) (82). The items adapted Committee of the Ramón de la Fuente Muñiz National Institute of from the BTQ assessed exposure to a major natural disaster, having lived Psychiatry (CEI/C/019/2021) and conformed to the Helsinki Declaration. in a place of war/terror or exposure to casualties, and experiencing the A total of 866 individuals completed the survey. Of these, 38 were violent or unexpected death of a close family member or friend. The excluded for not meeting the inclusion criteria. We also excluded six items adapted from the QSLE assessed exposure to peer bullying and participants who self-reported a psychotic disorder or a psychosis- intimate partner violence. Items were answered dichotomously (yes/no) related hospitalization. Thus, the analytic dataset included and examined separately in the statistical analyses. 822 participants. 2.2.5. COVID-related distress The level of distress associated with the COVID-19 pandemic and 2.2. Measures lockdown was assessed using the following question: “On a scale from 0 (not at all) to 10 (very much), how much distress has the pandemic and 2.2.1. Sociodemographic questionnaire COVID-19 lockdown caused you?,” with higher scores indicating greater Participants provided sociodemographic information, including levels of COVID-related distress. age, sex, marital/relationship status, place of birth and residence, educational level (highest completed degree), current occupation, and 2.2.6. Cannabis risk level socio-economic status based on monthly family income: low < 9,000 The Alcohol, Smoking, and Substance Involvement Screening Test MXN; medium > 9,000 and < 45,000 MXN; high > 45,000 MXN (1 MXN (ASSIST) (83, 84) was used to determine the level of risk associated with is equivalent to approximately .05 USD). They also provided information cannabis use. It comprises 8 items that assess the degree of substance Frontiers in Psychiatry 03 frontiersin.org Domínguez-Martínez et al. 10.3389/fpsyt.2023.1095222 involvement for several substances, including cannabis. Specifically, previously described cut-offs for clinically significant exposure for the items measure lifetime and current (past 3 months) use, urge to CTQ maltreatment subscales. Two models are presented, the first one consume, problems associated with use, failure to complete role containing all the variables in the first step of the modeling approach, obligations due to use, the concern expressed by others regarding and the second including only those variables that remained in the consumption, and failure to stop or cut down use. The ASSIST provides model after the backward stepwise process and which has the most a dimensional risk score for cannabis (a sum score that ranges from 0 to adequate goodness of fit. All tests were deemed to be significant with 39), which determines the level of risk: lower (0–3), moderate (4–26), or a p ≤ 0.05. For the analyses, the SPSS version 21 statistical package high (27 or more). Individuals with lower risk are not considered to was used. require intervention, whereas those with moderate and high risk are deemed to require intervention. Previous research has supported the use of computer- and web-based modalities to administer the ASSIST 3. Results (85, 86). 3.1. Sociodemographic factors 2.2.7. Family functioning The 6-item general functioning subscale (GF6+) (87) of the The final study sample consisted of 822 individuals. The sample was McMaster Family Assessment Device (FAD) (88, 89) was used to assess predominantly female (78.2%, n = 643), with a mean age of 29.1 years overall family functioning. Items are scored on a 4-point scale ranging (S.D. = 8.3, range 15–45). Most participants were single (55.5%, n = 456; from “strongly agree” to “strongly disagree,” with higher scores denoting with partner = 40.6%, n = 334; separated/divorced 3.9%, n = 32), with a worse family functioning. A mean score higher than 2 is indicative of an higher percentage reporting at least a bachelor’s degree (64.4%, n = 529) unhealthy family functioning. as well as having an economically remunerated activity (51.9%, n = 427) or being students (35.8%, n = 294). Less than half of the sample self- reported a mental health problem (32.8%, n = 270). Of those with a 2.3. Statistical analyses reported mental health problem, affective (28.1%, n = 76) and anxious symptomatology (27.8%, n = 75) were the most frequently reported. The For sample description, frequencies and percentages were used to remaining sociodemographic features are displayed in Table 1. summarize categorical variables, and means and standard deviations When dividing the sample into the CHR-positive group and the (S.D) were calculated for the continuous variables. For testing Non-CHR group, 17.3% (n = 142) met the combined PQ-B and SFQ normality, skewness and kurtosis of the variables were calculated. A criteria for a CHR-positive screen. As reported in Table 1, no differences skewness value over 2 and kurtosis value over 7 are considered to emerged between the groups in terms of sex, marital/relationship status, be indicative of moderate or important non-normality (90). Overall, current occupation, or socio-economic status. Nevertheless, a higher the skewness and kurtosis ranges found in our variables were not out percentage of individuals from the CHR-positive group reported lower of the norm, with a skewness range from −1.37 to 2.21 and a kurtosis educational levels, more self-reported mental health problems, and were range between −1.98 and 4.76. The only variable that exhibited a younger than those in the Non-CHR group. higher outside range for skewness (3.92) and kurtosis (13.41) was the item asking whether participants had lived in a place of war/terror or had been exposed to casualties. Given the limited evidence of 3.2. Psychosocial factors non-normality, Chi-square tests (χ2) and independent sample Student’s t-tests were used to compare the study variables between those who Most of the participants reported a low risk of presenting problems screened positive for CHR (CHR-positive group) and those who did associated with cannabis consumption (87.1%, n = 716). However, a not (Non-CHR group). The sociodemographic (age, sex, marital/ higher percentage of CHR-positive individuals reported medium/high relationship status, educational level, current occupation, and socio- risk compared to the Non-CHR group. As displayed in Table 2, in economic status) and psychosocial factors (abuse and neglect during terms of experiences of adversity, no differences arose between groups childhood, traumatic events, the risk of presenting problems associated regarding the experience of living in a place of war/terror (5.5%, n = 45 with the use of cannabis, and family functioning) were included as of the total sample) or experiencing a major natural disaster (20.2%, possible predictors associated with a CHR-positive screen in a n = 166 of the total sample). Nevertheless, a higher percentage of those multivariate logistic regression analysis using the backward conditional screening positive for CHR experienced a violent or unexpected death modeling approach. To determine the goodness of fit of the models, of a relative or friend, peer bullying, and intimate partner violence. the Hosmer-Lemeshow test was used (91). Some variables were This group also reported poorer family functioning, more distress classified (dummy coded) into auxiliary variables to perform this associated with the COVID-19 pandemic and lockdown measures, analysis using their defined cut-off points and were represented by two and higher levels of childhood maltreatment across all the CTQ values, “0” and “1,” where the latter represents the risk/present value. subscales. The differences in childhood maltreatment also emerged In particular, the variables were coded as follows: marital/relationship when considering the thresholds for the presence of clinically status (0 = partnered, 1 = divorced/separated, single), socio-economic significant levels of exposure. In particular, as compared with the level (0 = medium and high, 1 = low), educational level (0 = bachelor Non-CHR group, the CHR-positive group reported higher rates of studies and higher, 1 = high school studies or less), current occupation emotional abuse (81.7%, n = 116 vs. 48.5%, n = 330; p < 0.001), physical (0 = student, economically remunerated activity, 1 = unemployed, abuse (62.0%, n = 88 vs. 36.6%, n = 249; p < 0.001), sexual abuse (43.7%, non-remunerated activity), cannabis risk level (0 = low risk, n = 62 vs. 25.7%, n = 175; p < 0.001), emotional neglect (49.3%, n = 70 1 = moderate/high risk), family functioning (0 = healthy functioning, vs. 22.8%, n = 155; p < 0.001), and physical neglect (57.7%, n = 82 vs. i.e., score ≤ 2, 1 = unhealthy functioning, i.e., score > 2), and the 31.2%, n = 212; p < 0.001). Frontiers in Psychiatry 04 frontiersin.org Domínguez-Martínez et al. 10.3389/fpsyt.2023.1095222 TABLE 1 Comparison of sociodemographic factors between the CHR-positive and Non-CHR groups. Total n=822 Non-CHR n=680 CHR-positive n=142 Statistics Demographic features n % Sex–Women 643 78.2 536 78.8 107 75.4 χ2 = 0.8, p = 0.36 Age–years (mean; S.D.) 29.1 8.3 29.7 8.3 26.4 7.6 t = 4.2, p < 0.001 Marital/relationship status  Single 456 55.5 373 54.9 83 58.5 χ2 = 5.3, p = 0.14  Married/cohabiting 185 22.5 163 24.0 22 15.5  Has a romantic partner 149 18.1 118 17.4 31 21.8  Separated/divorced 32 3.9 26 3.8 6 4.2 Level of completed education  Elementary school 2 0.2 2 0.3 0 χ2 = 29.7, p < 0.001  Secondary school 24 2.9 15 2.2 9 6.3  Technical career 11 1.3 8 1.2 3 2.1  High school 256 31.1 193 28.4 63 44.4  Bachelor studies 370 45.0 315 46.3 55 38.7  Postgraduate 159 19.3 147 21.6 12 8.5 Current occupation  Student/economically remunerated activity 721 87.7 603 88.7 118 83.1 χ2 = 3.3, p = 0.06  Unemployed/non-remunerated activity 101 12.3 77 11.3 24 16.9 Socioeconomic status*  Low 262 31.9 207 30.4 55 38.7 χ2 = 5.8, p = 0.053  Medium 502 61.1 420 61.8 82 57.7  High 58 7.1 53 7.8 5 3.5 Self-reported mental health problem–Yes 270 32.8 198 29.1 72 50.7 χ2 = 24.8, p < 0.001 *Low: < 9,000 MXN; medium: ≥ 9,000 and ≤ 45,000 MXN; high: > 45,000 MXN. 3.3. Factors associated with screening positive for CHR. Finally, in line with emerging work on the mental positive for a CHR for psychosis health impact of the COVID-19 pandemic, COVID-related distress also emerged as a significant risk factor. Overall, these results add to current The variables associated with screening positive for CHR for efforts to identify commonalities and specificities of risk factors for psychosis in the present sample were: having an unhealthy family psychosis across different sociocultural contexts. functioning, a higher risk related to cannabis use, a lower level of We found that 17.3% (n = 142) of this Mexican sample screened completed education, having experienced a major natural disaster, positive for a CHR for psychosis, which is higher than the rate (1.7%) having experienced a violent or unexpected death of a relative or friend, reported in the most recent systematic review and meta-analysis of the clinically significant levels of emotional abuse, physical neglect, and prevalence of CHR in the general population (18). There are several physical abuse during childhood, and higher distress associated with the potential reasons for this finding. First, this could be associated with the COVID-19 pandemic. An older age was a protective factor for screening evidence that the prevalence rates of psychotic-like experiences vary positive for CHR. The results of the initial and final logistic regression across countries of different income levels, with a higher prevalence models are displayed in Table 3. reported in low- and middle-income countries than in high-income countries (7, 70). Second, the prevalence in this sample could be related to the recent impact of the COVID-19 pandemic. Worldwide, several 4. Discussion studies have shown an increase in mental health problems in the general population during the COVID-19 pandemic (92–95), including an To the best of our knowledge, this is the first study to explore increase in psychotic-like experiences (9, 10, 11, 96). However, due to sociodemographic and psychosocial factors associated with the risk of the lack of pre-pandemic studies on the prevalence of CHR in the developing psychosis in a Mexican sample. Our results showed that the Mexican population, we are unable to draw any conclusions regarding CHR-positive group had higher levels of environmental risk than the the impact of the pandemic in this respect. Additionally, the higher Non-CHR group. Furthermore, regarding the variables associated with prevalence could also be due to the use of self-report measures for the a CHR-positive screen, an unhealthy family functioning and cannabis designation of risk status. Future studies using interview measures for risk level were the strongest predictors. In addition, consistent with the detection of CHR individuals in the Mexican general population current evidence in the literature, age, educational level, childhood may help clarify the potential impact of the assessment method on maltreatment, and traumatic events were also associated with screening prevalence rates. Frontiers in Psychiatry 05 frontiersin.org Domínguez-Martínez et al. 10.3389/fpsyt.2023.1095222 TABLE 2 Comparison of psychosocial factors between the CHR-positive and Non-CHR groups. Total n=822 Non-CHR n=680 CHR-positive n=142 Statistics Cannabis risk level n % Cannabis risk level–moderate/high 106 12.9 68 10. 38 26.8 χ2 = 29.3, p < 0.001 Adverse experiences n % Lived in a place of war/terror–yes 45 5.5 38 5.6 7 4.9 χ2 = 0.09, p = 0.75 Experienced major natural disaster–yes 166 20.2 129 19.0 37 26.1 χ2 = 3.6, p = 0.056 Experienced a violent or unexpected death–yes 319 38.8 248 36.5 71 50.0 χ2 = 9.0, p = 0.003 Experienced bullying–yes 438 53.3 338 49.7 100 70.4 χ2 = 20.2, p < 0.001 Experienced intimate partner violence–yes 406 49.4 324 47.6 82 57.7 χ2 = 4.7, p = 0.02 Childhood maltreatment Mean S.D. Emotional abuse 11.2 5.4 10.4 5.0 15.1 5.5 t = −9.9, p < 0.001 Physical abuse 8.2 4.2 7.8 3.8 10.2 5.1 t = −5.3, p < 0.001 Sexual abuse 7.8 4.7 7.5 4.5 8.9 5.3 t = −2.8, p < 0.001 Emotional neglect 11.4 4.8 10.9 4.7 14.0 4.8 t = −7.0, p < 0.001 Physical neglect 7.4 3.0 7.1 2.9 8.9 3.3 t = −5.7, p < 0.001 Total score 46.2 16.9 43.9 15.6 57.2 18.6 t = −7.9, p < 0.001 Family functioning Family functioning (mean S.D.) 2.0 0.7 1.9 0.7 2.5 0.6 t = −8.7, p < 0.001 Unhealthy family functioning–yes (n %) 383 46.6 273 40.1 110 77.5 χ2 = 65.7, p < 0.001 COVID-related distress Mean S.D. COVID-related distress 6.08 2.52 5.9 2.5 6.9 2.5 t = −4.2, p < 0.001 4.1. Differences between CHR-positive and 4.2. Factors associated with a positive screen non-CHR groups for CHR The findings of the comparisons between the CHR-positive and In line with prior studies (e.g., 10, 40), findings regarding Non-CHR groups showed that individuals screening positive for CHR sociodemographic characteristics showed that being older is a protective were younger and reported lower educational levels than those in the factor, as it was associated with a lower risk of screening positive for Non-CHR group. These differences might be interrelated, as the lower level CHR. Furthermore, a lower educational level emerged as a risk factor. of highest education attained by the CHR-positive group may correspond Although this supports what has been shown in previous work (10, 44), to their average younger age. Moreover, the CHR-positive group self- we interpret this finding with caution, as the most frequent level of reported more mental health problems than the Non-CHR group, which education completed by the CHR-positive individuals in our sample was is consistent with the clinical features of the at-risk stages described in the high school, which represents a high or above-average educational level for literature, characterized by the presence of a wide range of non-specific the Mexican population (108). Therefore, more research in larger and more psychopathology and a high prevalence of non-psychotic psychiatric representative Mexican samples is required to confirm it as a risk factor. comorbidity, especially with depressive and anxiety disorders (97–100). This study found that an unhealthy family functioning was an The findings regarding differences in the psychosocial domain are important psychosocial factor associated with screening positive for in line with previous studies indicating that cannabis misuse, childhood CHR for psychosis. This result is notable in light of the centrality of maltreatment, bullying, and traumatic events are more prevalent among family relationships in the Mexican sociocultural context (109, 110) and CHR individuals, as compared with healthy controls or the general seems consistent with the finding that the sociocultural context influences population (32, 37, 47, 67, 101–103). We also found that the the extent to which components of family functioning are linked to CHR-positive group reported poorer family functioning and more psychotic-like experiences, with a stronger association in developing distress associated with the COVID-19 pandemic than the Non-CHR countries than in highly industrialized countries (60). Future studies group. Although comparisons on these variables are scarcer in the directly assessing cultural processes in the Mexican context can enrich literature, the findings are consistent with the evidence that CHR our understanding of how culture shapes the interrelations between individuals report worse family functioning or less family satisfaction family factors and psychosis (65, 111, 112). Although family functioning than Non-CHR individuals (104–106). In addition, they support the has been less extensively investigated as a predictor of CHR states, results of a recent study suggesting an association between psychotic- existing research on the family environment has indicated that negative like experiences and a greater psychological impact of the COVID-19 family affect and family stress (e.g., criticism, communication problems, pandemic (107). Further research on the effects of the COVID-19 less support and cohesion) are associated with poor outcomes across the pandemic on this population is needed to confirm this finding and its psychosis continuum, including young people vulnerable to psychosis potential clinical implications. (55, 56, 58, 113–115), while certain components of a positive family Frontiers in Psychiatry 06 frontiersin.org Domínguez-Martínez et al. 10.3389/fpsyt.2023.1095222 TABLE 3 Factors associated with screening positive for CHR for psychosis. Initial Model Final Model OR 95% C.I. OR 95% C.I. Sex–men 1.34 0.79 2.25 - - - Age 0.95** 0.91 0.98 0.96* 0.92 0.99 Marital/relationship status–single/not partnered 0.81 0.52 1.28 - - - Level of completed education–high school or less 1.52 0.92 2.50 1.55* 1.003 2.54 Current occupation–unemployed/not remunerated 1.40 0.77 2.53 - - - Socioeconomic status–low 1.11 0.71 1.73 - - - Cannabis risk level–moderate/high 2.63*** 1.53 4.49 2.75*** 1.63 4.64 Lived in a place of war/terror–yes 0.89 0.34 2.31 - - - Experienced major natural disaster–yes 1.90* 1.15 3.15 1.94** 1.18 3.16 Experienced a violent or unexpected death–yes 1.83** 1.20 2.79 1.85** 1.22 2.81 Experienced bullying–yes 1.43 0.90 2.28 - - - Experienced intimate partner violence–yes 1.12 0.71 1.78 - - - Emotional abuse–clinically significant 1.73* 1.002 3.07 1.88* 1.09 3.25 Physical abuse–clinically significant 1.53 0.96 2.43 1.66* 1.05 2.61 Sexual abuse–clinically significant 1.34 0.84 2.14 - - - Emotional neglect–clinically significant 1.23 0.74 2.03 - - - Physical neglect–clinically significant 1.50 0.93 2.40 1.68* 1.08 2.61 Family functioning–unhealthy 2.58*** 1.56 4.25 2.75*** 1.69 4.46 COVID-related distress 1.11 1.02 1.21 1.10* 1.01 1.20 Initial model: R Nagelkerke = 0.31 Test Hosmer and Lemeshow = p = 0.34 Final model: R Nagelkerke = 0.30 Test Hosmer and Lemeshow = p = 0.14 2 2 *p ≤ 0.05, **p ≤ 0.01***p ≤ 0.001 Hyphen (−) indicates variables which did not enter in the regression model. environment (e.g., warmth, positive remarks, family support, cohesion with vulnerability to psychosis (12, 27, 30, 37, 132, 133). In particular, and adaptability, quality of parent–child communication) seem to act as findings showed that a CHR-positive screen was associated with having protective factors in the early course of psychosis and have been found to experienced higher levels of emotional abuse, physical abuse, and predict improved symptoms or functioning over time in CHR individuals physical neglect during childhood, a major natural disaster, violent or (54, 105, 116–118). Since psychotic symptoms generally emerge during unexpected death of a relative or friend, and higher distress due to the adolescence and early adulthood, a period when individuals are typically COVID-19 pandemic. greatly impacted by family interactions, these findings suggest the The association of emotional abuse, physical abuse, and physical relevance of tailoring early family interventions to bolster family neglect with screening positive for CHR parallels previous research functioning and improve family communication, such as by emphasizing demonstrating that a history of childhood maltreatment represents a supportive interactions and family psychoeducation (117–120). strong risk factor for psychotic phenomena and the manifestation of Our findings also showed that having a moderate/high risk related the CHR state (19, 37, 39, 42, 47, 134). Furthermore, the findings to cannabis use was associated with a CHR-positive screen, which is in regarding emotional abuse are in line with a recent review showing that line with previous research demonstrating an association of cannabis use emotional abuse is the type of adversity most strongly associated with with psychotic symptoms and psychotic disorders (121–123). Although subclinical expressions of psychosis in non-clinical samples (135). there is strong evidence indicating a dose–response relationship between Therefore, our results concerning childhood maltreatment support cannabis use and psychosis (27, 124, 125), conflicting findings have also those obtained across other populations and further highlight the emerged (19) and the evidence of the effect of cannabis use on the relevance of distinguishing among maltreatment types when exacerbation of attenuated psychotic symptoms in CHR individuals is investigating associations with psychosis risk. inconsistent (33, 126). Current research on cannabis and psychosis has Interestingly, some of the other environmental experiences associated highlighted several moderating factors, including genetic variability as with screening positive for CHR in this sample, such as having well as the frequency and age of onset of cannabis use (127, 128). Thus, experienced a major natural disaster and the violent or unexpected death it will be essential for future research conducted in the Mexican context of a relative or friend, have been less prominent in the literature but seem to examine these factors, especially considering that the COVID-19 consistent with the particular adverse life experiences of the Mexican pandemic may have impacted the patterns and frequency of cannabis use population. In recent years, the violence in Mexico has increased (129, 130) and that the mean age of onset of cannabis use in Mexico has substantially, with a historical record of femicides, homicides, and forced been decreasing in recent years (131). disappearances due to organized crime (136). Furthermore, over recent Consistent with a robust body of work, we found that early and decades, the Mexican population has experienced multiple natural subsequent exposure to psychosocial stress and adversity was associated disasters, such as the 2017 earthquakes, as well as floods caused by Frontiers in Psychiatry 07 frontiersin.org Domínguez-Martínez et al. 10.3389/fpsyt.2023.1095222 hurricanes and tropical storms that have resulted in numerous deaths 4.5. Conclusion and many victims (damnificados). In addition, although studies are still limited, the daily stressors during the COVID-19 pandemic have In closing, this study contributes to the body of research examining impacted the mental health of the Mexican population (137)—and our sociodemographic and psychosocial factors associated with an elevated results suggest that this stress may also be associated with the risk of risk for psychosis across different countries and populations. In psychosis. Therefore, further epidemiological and longitudinal research particular, we provided, to our knowledge, the first examination of this with larger samples is required to better understand the potential topic in the Mexican population. Several of the risk factors that medium- and long-term impact of the psychosocial stress and traumatic emerged as relevant in the present study have been widely reported in events identified as risk factors in the present study. the literature, while the significance of other, less extensively studied factors seems consistent with the sociocultural fabric and experiences of the Mexican population. The current work represents a starting place 4.3. Clinical implications for future studies to build upon, especially by examining these factors longitudinally as well as their interactions with genetic susceptibility. The findings of this study have several clinical implications. The Overall, this study highlights the importance of examining potential high rate of individuals with a CHR-positive screen in this Mexican contributors to psychosis vulnerability across different sociocultural sample is alarming and underscores the need to prioritize and contexts to delineate risk and protective processes relevant to specific promote early detection programs and preventive interventions populations and better target preventive intervention efforts. focused on the early stages of psychosis, which are almost nonexistent in Mexico. Furthermore, if replicated, the psychosocial variables identified as risk factors could help to guide preventive interventions Data availability statement in the population with potential risk for developing psychotic disorders. For instance, both family functioning and cannabis use are The datasets presented in this article are not readily available due to amenable to intervention. Therefore, preventive strategies and early ethical restrictions regarding the privacy of research participants. Requests interventions could benefit from a focus on reducing dysfunctional to access the datasets should be directed to tecellid@imp.edu.mx. family dynamics (54), as well as educational, psychological, and social interventions to reduce cannabis use and its associated risks in CHR adolescents and young adults (31). In addition, the findings support Ethics statement prior calls to make routine and sensitive inquiries about childhood adversity when working with individuals presenting with psychosis- The studies involving human participants were reviewed and spectrum psychopathology, as well as the importance of implementing approved by the Research Ethics Committee of the Ramón de la Fuente effective treatments for childhood trauma in this population (67, 138, Muñiz National Institute of Psychiatry (CEI/C/019/2021). All 139). Moreover, considering the context of humanitarian emergencies participants aged 18 and older provided informed consent. Minor and generalized violence that the Mexican population has participants provided informed assent and their parents/legal guardians experienced, it is necessary to create crisis-focused interventions to provided informed consent. reduce the impact of these events on people’s mental health and psychosocial well-being (140). Author contributions 4.4. Limitations TD-M was the principal investigator, oversaw data collection, conceived the study, and contributed to writing—original draft, review, The current research has certain limitations that should and editing. TS contributed to the scoring/management of the data and be considered when interpreting the results. First, the cross-sectional writing—original draft, review, and editing. AF conducted the data nature of the study limits the inferences that can be drawn in terms of analysis and contributed to writing—original draft, review, and editing. causality. Second, all measures were self-reports, which are susceptible All authors critically revised the manuscript for important intellectual to reporting biases. Concerning the designation of a CHR status content and approved the submitted version. through self-report measures, we note that we attempted to mitigate this limitation by using strict criteria that included both PQ-B and SFQ cut-offs to establish a CHR-positive screen and that previous work has Funding supported the possibility of detecting CHR individuals through online screening (141). However, it would have been preferable to use widely- This study was supported by Programas Nacionales Estratégicos del validated semi-structured interviews, such as the SIPS (16) or the Consejo Nacional de Ciencia y Tecnología (CONACyT-PRONACES), CAARMS (13). In this regard, it is relevant to note that a recent large- grant 3205. scale study found that both self-report and interview measures of psychotic experiences were associated with similar risk indicators (142). Finally, our use of a non-random sampling technique Conflict of interest (participants were individuals with Internet access who were interested in responding to the survey) and the fact that the sample was The authors declare that the research was conducted in the absence predominantly female with a relatively high educational level limit the of any commercial or financial relationships that could be construed as generalizability of the results. a potential conflict of interest. Frontiers in Psychiatry 08 frontiersin.org Domínguez-Martínez et al. 10.3389/fpsyt.2023.1095222 Publisher’s note organizations, or those of the publisher, the editors and the reviewers. 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