Abstract
• Students from countries across the world report high levels of mental disorder comorbidity.
• Temporally primary internalizing and externalizing disorders are strongly associated with the first onset of other mental disorders in students.
• Students with disorders across the internalizing and externalizing spectrum could potentially benefit from secondary prevention strategies.
Background: Mental disorders are highly prevalent among students worldwide. This study aims to examine comorbidity and temporal associations between mental disorders among students.
Methods: The study included 72,288 students from 18 countries as part of the World Mental Health International College Student (WMH-ICS) Initiative, with cross-sectional data collected between 2017 and 2023. Screening for common DSM-5 disorders was conducted using validated screening measures. Latent variables were examined using exploratory principal axis factor analysis on a correlation matrix among the lifetime mental disorders. Based on age-of-onset information, multivariable poisson regression models were used to examine associations of prior disorders with the first onset of other disorders.
Results: 27.0 % of students screened positive for only one lifetime disorder, 17.1 % for two, 10.9 % for three, and 10.6 % for 4+ disorders. In the factor analysis, three latent variables were found, comprising: internalizing disorders (generalized anxiety disorder, major depressive episode, post-traumatic stress disorder, and panic disorder), substance use disorders (drug use disorder and alcohol use disorder), and externalizing disorders (attention deficit/hyperactivity disorder and mania/hypomania). Prior internalizing and externalizing disorders were associated with the subsequent first onset of all other disorders with risk ratios ranging from 1.5-7.5. Substance use disorders were less consistently associated with the subsequent first onset of other disorders, but alcohol use disorder was associated with the first onset of drug use disorder and vice versa.
Conclusions: Mental disorder comorbidity is common among students, and students with disorders across the internalizing and externalizing spectrum have an increased risk of future mental disorder comorbidities.