Perpetrating-Suffering Intimate Violence: Self-Harm-Suicide Thoughts and Behaviors, Mental Health, and Alcohol Use among Mexican Youth during COVID-19

doi:10.21203/rs.3.rs-4836554/v1

Background

The COVID-19 epidemic had a deleterious impact on mental health and substance abuse as well as an increase in several forms of violence including self-harm, and interpersonal violence, among youth from low- and middle-income countries. However, the relationship among these variables and its directionality have not been established. The study describes the trends and relationship directionality between these variables among young adults during the COVID-19 pandemic in Mexico.

Methods

This longitudinal cohort study comprises an evolving group of young Mexican adults: 1,390 participants aged 18 in 2021, 654 aged 19 in 2022, and 442 aged 20 in 2023. Proportions by sex—50% were matched in every cohort, and the evolution-age sample accomplishment accounted for 47% in 2022 and 32% in 2023.

Results

According to a structural equation model, which fit the data from 195 iterations with 246 parameters (X² [2,722] = 8,327.33, p < 0.001), yielding a CFI of 0.946, a TLI of 0.943, and an RMSEA of 0.029 [0.028–0.029]), perpetrating intimate violence, preceded by suffering intimate violence, combined with suffering anxiety symptoms, was associated with self-harm suicide thoughts and behaviors (ShSTB), marked distress, dysfunction, and somatization symptoms. The relationship was stronger in women and 20-year-old Mexicans. In men, this pathway was exclusively associated with ShSTB. Suffering from intimate violence has been associated with depression, anxiety, and PTSD symptoms, as well as harmful alcohol use.

Conclusion

During an epidemic, prevention programs should be designed to warn about self-harm-suicide thoughts and behavior, not only to ensure the safety of the victims of intimate-personal-violence victim but also to prevent the suicidal behavior of perpetrators.

perpetrating-intimate-violence

self-harm-suicide thoughts-behaviors

mental health

harmful-alcohol-use

cohort study

The COVID-19 pandemic directed attention to self-harm and suicidal thoughts and behaviors (ShSTB), in addition to the increase in perpetrating-suffering intimate-interpersonal violence, mental health symptoms, and harmful alcohol use in youth from low and middle-income countries (LMICs). Previous data suggest a relationship between perpetrating-suffering intimate violence and ShSTB, with alcohol use and mental health symptoms as associated factors. Describing trends and relationship directionality between violence, ShSTB, mental health symptomatology, and alcohol is needed to contribute to the development of effective self-harm-suicide prevention programs in young people in LMICs suffering or perpetrating violence.

Suicide is the fourth leading cause of death among 15-29-year-olds, with 77% of global suicides occurring in LMIC [1]. In Mexico, self-harm accounted for 5.3 (95% UI 4.28–6.46) deaths per 100,000 population in 2019, showing an upward trend since 2000 [2], with 2.2 (95% UI 1.73–2.70) and 8.7 deaths per 100,000 population (95% UI 7.06–10.60) for women and men, respectively. These disease burden levels place Mexico in the 3.40 to 60 quintiles across all countries. In a previous study of 18,449 Mexicans during the COVID-19 pandemic, we reported that 33.30% of our participants presented at least one ShSTB symptom, 4.20% had had previous self-harm thoughts and behaviors (PShTB), while 38.30% reported marked distress, dysfunction, and somatization (MDDS; [3]).

Young people aged 10–29 have experienced at least one form of assault [4]. The United Nations Office on Drugs and Crime Research—Data Portal—Violent and Sexual Crime (UNODC [5]) reported a steady trend in sexual violence as the only violent offense data available for Mexico, with a global rate of 2.47 per 100,000 population in 2015, 3.46 in 2016, 2.89 in 2017, 2.82 in 2018, 1.96 in 2019, 3.71 in 2020, 6.00 in 2021, and 7.22 in 2022. In a recent longitudinal study of 5,102 Mexicans aged 18–24, we found that 35.20% of young participants perpetrated interpersonal violence and 22.85% intimate violence, while 40.38% had experienced intimate violence between 2021 and 2023 [6].

The COVID-19 pandemic led to a 27.6% increase in depression cases and a 25.6% increase in anxiety disorders in 2021 [7]. The Pan American Health Organization [8] observed a 6.5% increase in mental health problems (8.9% in women and 3.2% in men) in Mexico between 2000 and 2019. The rate was 1,716.4 YLD per 100,000 Mexicans in 2019 (1,975.7 for women and 1,438.2 for men). Our preliminary cohort-longitudinal study during the pandemic indicated a prevalence of depression, anxiety, and PTSD symptoms among Mexican youth of 47.43%, 52.21%, and 27.28%, respectively [6].

Alcohol consumption is responsible for 2.6 million deaths each year globally. It is the leading factor for premature mortality and disability among those aged 20 to 39, accounting for 13% of the deaths in this age group [9]. In Mexico, harmful alcohol use rose from 28% in 2011 to 33.6% in 2016 (from 15.5–22.6% in women and from 41.3–45.5% in men, National Report on Alcohol and Tobacco published by the Ramón de la Fuente Muñiz National Institute of Psychiatry [Spanish acronym INPRFM], [10]). Our longitudinal-cohort study indicated that 21.31% of Mexican youth reported harmful alcohol use during the pandemic [6].

The prevalence of ShSTB, MDDS, perpetrating-suffering intimate-interpersonal violence, depression, anxiety, PTSD, and harmful alcohol use in Mexico during the pandemic underscores the importance of knowing the developmental trends and the relationship directionality between them, as well as the moderating role of sex, for enhancing cost-effective preventive interventions and public mental health treatment. As Rooney et al. [11] conclude, understanding the determinants of suicide ideation and actions is a crucial goal for this area of research.

Perpetrating intimate violence and having ShSTB have common risky social determinants, including early exposure to adversity (such as witnessing or being a victim of intimate violence), substance use, and mental health problems [12]. Rooney et al. [11] even indicated that experiencing suffering and perpetrating violence may provide youth with the capability (such as fearlessness and the physical means) to engage in suicidal behavior.

There is evidence to support the association between various psychosocial conditions (such as depression, hopelessness, social isolation, and adverse life events) and suicidal thoughts. We previously explored the relationship between depression, anxiety, and related MDDS with ShSTB by sex in Mexican adults during the COVID-19 pandemic [3]. Our findings suggest that depression leads to ShSTB in three possible ways: through PShTB, PShTB affecting MDDS, and generalized anxiety affecting MDDS. Predisposing factors for ShSTB would appear to include depression, anxiety, and hopelessness. Substance use, access to lethal means, involvement with the criminal justice system, family conflict, and dating problems have been identified as factors associated with ShSTB [13].

Exposure to interpersonal violence is associated with suicide attempts and suicide among youth and young adults [14]. Among adults, those who perpetrate violence are more likely to report suicide attempts [15]. Research examining suicide risk among victims of bullying (in other words, those who bully others and are bullied themselves) suggests that they are at greater risk for suicide than those who are only victims or perpetrators [16]. Wolford-Clevenger et al. [17] also found a high prevalence of non-fatal suicidal ideation among perpetrators of violence.

Kafka et al. [13] evaluated the nature of intimate violence prior to suicide by sex between 2010 and 2017 in North Carolina. They noted whether the person who died by suicide was described as a perpetrator of violence, a victim, or both (bilateral violence), recording the type of abuse, whether physical or emotional, verbal threats to harm/kill, illegal trespassing, sexual assault, or stalking, and abusive suicide-related threats in the two weeks prior to their death. They described 439 suicides in which 72.67% of male decedents had perpetrated non-fatal intimate violence compared to 51.22% of female decedents, who also reported perpetrating intimate violence. Kafka et al. [13] concluded that intimate personal violence may be a precipitating factor in 6.1% of suicides in North Carolina. Over 80% of decedents had engaged in nonfatal intimate personal violence prior to their suicide, while intimate violence was more common for youth involved in the criminal legal system, who revealed suicidal intent and used a firearm or alcohol. Kafka et al. [13] also reported a negative association with depression. A systematic review by Sesar et al. [18] identified nine studies examining the association between perpetrating intimate violence and nonfatal suicidal behaviors in community and clinical samples, concluding that suicide is an impulsive response to acute strain or conflict in an already abusive relationship.

Rooney et al. [11] examined the association between suffering, perpetrating, and attempting suicide in a national sample of American youth reporting suicide ideation in the past year, suggesting that those who both experience and perpetrate violence are at greater risk for engaging in suicide behaviors with a cumulative effect. The authors worked with 821 participants who indicated that they had seriously thought about committing suicide in the past year—63.1% female, 64.7% white, and 12.1% Hispanic. Rooney et al. [11] used stepwise hierarchical regressions to examine the association between victimizing and perpetrating violence and attempting suicide, reporting that 52.7% suffered some form of aggression, 30.8% perpetrated some form of violence, and 28% attempted suicide in the past year. In general, the authors concluded that victimizing and the interaction between victimizing and perpetrating violence were associated with the frequency of attempting suicide, over demographics, depression, and other non-violent externalizing behaviors.

While both victimizing and perpetrating violence are associated with suicidal behaviors generally, there is a need of research on suicide thoughts and behaviors among those who are both suffering and perpetrating violence [11]. Additionally, further research needs to confirm how perpetrating intimate violence precipitates single suicides unrelated to other violent deaths [13]. Rooney et al. [11] suggested additional research throughout a prospective-longitudinal studies to better evaluate the effects of victimizing and perpetrating violence on attempting suicide over time.

Prevalence of ShSTB, intimate violence, mental health symptoms, and harmful alcohol use was high in Mexico during the pandemic. Previous independent studies also suggest an association between ShSTB and suffering-perpetrating intimate-interpersonal violence and mental health conditions and harmful alcohol use in Mexico [3; 6]. A cohort-longitudinal study could, therefore, help identify the association between perpetrating-suffering violence, ShSTB, mental health, and alcohol use and their trends in a young Mexican population during the pandemic. This study describes the trends and relationship directionality between perpetrating and suffering intimate violence, ShSTB, mental health symptoms, and harmful alcohol use among young adults through a longitudinal cohort study during the COVID-19 pandemic in Mexico. Our hypotheses state that perpetrating intimate violence and suffering intimate violence are associated with ShSTB (Ha1 and Ha2), as well as depressive, anxious, and PTSD symptoms (Ha3, Ha4, and Ha5), and harmful alcohol use (Ha6) in one evolving age group.

2.1 Participants and design

We used a longitudinal, evolving group cohort of 2,486 Mexicans comprising 1,390 participants aged 18 in 2021 (55.91%), 654 aged 19 in 2022 (26.31%), and 442 aged 20 in 2023 (17.78%). As for proportions by sex, 50% were matched in every cohort, and the evolution-age sample achievement accounted for 47% in 2022 and 32% in 2023 (see Table 1).

Participants were invited to enroll voluntarily in a web-based application called My Health is also Mental (https://www.misalud.unam.mx, [19]), using their email addresses to complete an evaluation of their mental health status and receive free feedback and treatment if necessary. We used the criteria for internet E-surveys, such as data protection, development, testing, contact mode, advertising the survey, compulsory/voluntary participation, completion rate, cookies used, IP check, log file analysis, registration, and atypical timestamp considerations [20]. Since the survey platform automatically eliminates respondents who fail to complete the survey, we only obtained complete response rates.

Insert Table 1 approximately here

The protocol was approved with code FPSI/422/CEIP/157/2020 by the Institutional Review Board of Ethics Committee on Applied Research of the Psychology Faculty at the National Autonomous University of Mexico (UNAM). Participants were told that findings would be used for epidemiological research and that they could refuse to comply with the data requests and drop out at any point in the study. Informed consent was obtained from all those involved in the study. Although incentives were not offered, psychoeducational tools provided immediate feedback (such as infographics, videos, and Moodle ® courses on COVID-19, self-care, relaxation techniques, problem-solving, and socioemotional management skills). Participants were given information on obtaining remote psychological care from public health services, if required. Data were asymmetrically encrypted, and the database held in the official university domain, with security locks to protect data.

2.2 Instruments

We used the survey described by Morales-Chainé, Palafox et al. [3], which collected new data in the sociodemographic section (including sex and age) and the seven self-completion psychological tests (see Appendix A for further information).

The self-harm/suicide scales contemplate twenty-one yes/no dichotomic response items on three scales referring to symptoms now, in the past month, and in the past year from the mhGAP algorithm [3]. The first scale comprised ten items called ShSTB warning signs (such as current thoughts of self-harm). The second section consisted of three items called PShTB (such as acts of self-harm in the past year). The third section comprised eight items for the MDDS (such as marked distress). Based on the total score, we considered subjects in the at-risk group when they checked at least one symptom in each scale. The three-factor model resulted in an \(\:{X}^{2}\)(186) = 19,643.19, p < 0.001; an RMSEA = 0.075 (0.074–0.076), a CFI = 0.984, a TLI = 0.982, and an α = 0.94 Based on the total score, we considered subjects to be in the at-risk group when they checked at least one symptom on each scale.

The Life Events Checklist 5th edition (LEC-5; [21, 22]) screens for suffering-perpetrating intimate-interpersonal violence in past six months with 11 yes/no-dichotomic-response items adapted from criterion A of the Posttraumatic Checklist (PCL-5; [23; 24]). Each prompt included the origin of the violence (such as physical assault [… being attacked, hit, slapped, kicked, or beaten up]); was this physical abuse inflicted by a family member or your partner?). Morales-Chainé et al. [24] indicated that the suffering-intimate violence scales obtained an \(\:{X}^{2}\)(2) = 6.09, p < 0.048, an RMSEA = 0.017 (0.001–0.032), a CFI = 0.999, a TLI = 0.997, and an α = 0.76. They reported that the suffering-interpersonal violence scales obtained an \(\:{X}^{2}\)(13) = 343.57, p < 0.001, an RMSEA = 0.059 (0.053–0.064), a CFI = 0.949, a TLI = 0.917, and an α = 0.76. They also noted that the perpetrating-intimate model obtained identified exact parameters, obtaining an α = 0.68. Finally, they observed that the perpetrating-interpersonal violence scales obtained an \(\:{X}^{2}\)(2) = 94.634, p < 0.001, an RMSEA = 0.079 (0.066–0.093), a CFI = 0.952, a TLI = 0.855, and an α = 0.68. If participants checked any of the experiences of violent events in Criterion A, they were asked to choose the one that had bothered them most at the time. If they had had only one experience of violence, they were asked to choose the most severe event to answer the questions in part B of PCL-5.

The PCL-5 included 20 five-option-response items [25]. Responses ranged from not at all (0), slightly (1), moderately (2), quite a lot (3), to extremely (4) bothersome symptoms in the past month. We used the four-factor DMS-5 [23] structure [26]: reexperiencing, with five items, avoidance, with two items, negative alterations in cognitions and mood (NACM) with seven items, and hyperarousal with six items. In the WebApp, we included the less/more-than-a-month response for how long the symptoms had bothered the participant. Blevins et al. [26] reported that the four-factor structure was a model with a good fit, which Morales-Chainé et al. [24] replicated with an \(\:{X}^{2}\) (162) = 4,535.593, p < .001, a CFI = 0.916, a TLI = 0.901, an RMSEA = 0.076 (0.074–0.078), an SRMR = 0.044, and an α = 0.93. The PTSD criterion is considered when a subject selected a 2-response option or more for at least one of the B-items, one of the C-items, two of the D-items, or two of the E-items, and symptoms had been bothering them for over a month.

The Major-Depressive-Episode (MDE) checklist included the 11 five-option-response items from the DSM-5 [23]. The response options involved indicating how often subjects had experienced symptoms in the past twelve months: always (1), nearly always (2), sometimes (3), rarely (4), or never (5). Morales-Chaine et al. [24] obtained an \(\:{X}^{2}\) (42) = 1210.25, p < .001, a CFI = 0.954, a TLI = 0.939, an RMSEA = 0.072 (0.069–0.076), an SRMR = 0.034, and an α = 0.89. Several steps were followed to calculate the total score: part 1, part 2, part 3, and criterion A and B guidelines. The criteria for Part 1 were met when items one and two (Sadness or depressed mood? and Discouraged because of how things are going in your life?) were answered with options 1 or 2. The criteria for Part 2 were met when five or more items were answered with options 1 or 2 from items 2 to 10 and Part 1. The criteria for Part 3 were met when question 3 (Loss of interest or pleasure?) was answered with response options 1 or 2. Criterion A was met when part 1 and part 2 or 3 were completed. Criterion B was met when question 11 (Symptoms causing impairment in social, occupational, or other important areas of functioning?) was answered with response options 1, 2, or 3. Finally, an MDE was identified when criteria A and B were met [23].

The Generalized Anxiety (GA) scale (adapted from [27]) comprises five items with eleven response options. The response options ranged from zero (total absence of the symptom) to ten (total presence of the symptom) for whether subjects had felt anxious in the past two weeks. Morales-Chainé et al. [24] obtained an \(\:{X}^{2}\) (5) = 74.940, p < .001, a CFI = 0.998, a TLI = 0.995, an RMSEA = 0.043 (0.035–0.052), an SRMR = 0.005, and an α = 0.93. We, therefore, screened for GA by adding the score and dividing it by five. In keeping with the Goldberg et al. [27] study, an average of 60% was considered a high level of GA.

The WHO Alcohol, Smoking, and Substance Involvement Screening Test determines harmful use for ten groups of AOD: tobacco (cigarettes, chewing tobacco, cigars), alcoholic beverages (beer, wine, spirits), cannabis (marijuana, pot, grass, hash), cocaine (coke, crack), amphetamine-type stimulants (speed, meth, ecstasy), inhalants (nitrous, glue, petrol, paint, thinner), sedatives or sleeping pills (diazepam, alprazolam, flunitrazepam, midazolam), hallucinogens (LSD, acid, mushrooms, trips, ketamine), opioids (heroin, morphine, methadone, buprenorphine, codeine), and other drugs [28]. ASSIST consists of eight questions screening for harmful AOD use, including lifetime use; use in the past three months; having a strong desire to use the drug in question; health, social, legal, or financial problems; failing to do what is expected because of the use of the drug in question; other expressions of concern about the use of the drug in question; attempts to reduce the use of the drug in question; and 8) injecting any drug (non-medical use only). The first item has dichotomous options: yes (1) or no (0). Items two to five have a five-option response: never, once or twice, monthly, weekly, and daily or almost daily. The value of each response option varies from 0, 2, 3, 4, or 6 for item two; 0, 3, 4, 5, or 6 for item three; 0, 4, 5, 6, or 7 for item four, to 0, 5, 6, 7, or 8 for item five. Items six to eight have a three-option response: no, never (0); yes, it happened in the past three months (6); or yes, but not in the past three months (3). Reliability values fluctuated between 0.80 for the alcohol dimension and 0.91 for stimulants [29]. Confirmatory factor analysis (CFA) found a good test factor structure (\(\:{X}^{2}\) [1,583] = 50,863.65, p < 0.001, an RMSEA = 0.040, an SRMR = 0.032, a CFI = 0.920 and a TLI = 0.913). The score for harmful use of each substance is calculated by adding the answers to questions two to seven. In the current study, we used only the alcohol scale, for which neither questions one nor eight were used to calculate the score (see Appendix A). Subjects reporting injecting drugs are referred to specialized emergency care. ASSIST has proved to have good validity and reliability coefficients.

2.3 Data Analysis

For the present study, the factor structure for each scale was evaluated with the Confirmatory Factor Analysis CFA, using the maximum likelihood (ML) and the diagonally weighted least squares (DWLS) procedures [30; 31]. The overall fit of the models was evaluated using the chi-square goodness of fit test. We considered the fit indices for specified models that might be less affected by sample size. The Comparative Fit Index (CFI) and the Tucker-Lewis Index (TLI) are goodness-of-fit indices in proportion fit metrics. In contrast, the Root Mean Square Error of Approximation (RMSEA) and the Standardized Root Mean Square Residual (SRMR) are badness-of-fit indices that are not in proportion metrics. Here, models with CFI and TLI values greater than 0.900 and RMSEA and SRMR values of less than 0.08 and 0.06 were considered indicators of data fit [30; 31]. The SRMR index was not considered for categorical data as Li [30] recommended. We calculated their Cronbach’s alpha reliability once we had determined the final structure model of each scale.

To test our hypothesis, we obtained the scores for each scale and classified subjects who met the self-harm/suicide (ShSTB, MDDS), violence (LEC-5), PTSD (PCL-5), depression (MDE), anxiety (GA), and harmful use of alcohol (from the ASSIST) criteria for risk. We compared the distribution of participants regarding such criteria by sex and cohort year of the pandemic, performing chi-squared tests and considering p-values under 0.05 on distributions.

Finally, we ran several tested structural models of the association directionality from suffering and perpetrating intimate and interpersonal violence, ShSTB, MDDS, harmful alcohol use, and mental health symptoms. We analyzed the predictive models between variables, evaluating the mediating effects between violence, ShSTB, MDDS, damage due to alcohol use, and mental health symptoms through the Structural Equation Modeling (SEM) with a mixture of continuous and categorical variables [30; 31]. We obtained models by sex and cohort year of the pandemic, with their chi-squared test and fitting indices. All analyses were conducted using the Lavaan statistical package 0.6–11 in the integrated development environment RSTUDIO® statistical software 2022.02.0 from the R Core Team [32] of the Foundation for Statistical Computing. We also used SPSS Statistics 25 [33].

3.1 Confirmatory Factorial Analyses and Cronbach’s Alpha

Appendix B shows the replication CFAs of the ShSTB, MDDS, LEC-5, MDE, GA, PCL-5, and ASSIST scales. Data fitting showed CFIs and TLIs > 0.90, RMSEAs < 0.08, and SRMRs < 0.06-the latter for continuous data, for all scales. The reliability range of the scales ranged from 0.38 for the Perpetrating Interpersonal Violence scale to 0.97 for the NACM from the PCL-5 and the MDE. Cronbach’s alpha determines the degree of independence between dimensions.

3.2 Self-harm-Suicide, Violence, Depression, Anxiety, PTSD, and Harmful Alcohol Use for the Total Sample by Sex and Cohort-years

The distribution of participants at risk for ShSTB, MDDS, violence, depression, anxiety, PTSD, and harmful alcohol use in the total sample by sex and cohort year are shown in Table 2. In the overall sample and according to the cutoff score in the corresponding scales, 38.10% of participants were at risk for ShSTB and 40% for MDDS; 37.70% of participants were at risk for suffering intimate violence, 58.70% for suffering interpersonal violence, 19.10% for perpetrating intimate violence, and 32.50% for perpetrating interpersonal violence in the total sample during the pandemic. 71.00% of participants were at risk for depression, and 47.70% for anxiety, 43.10% were reexperiencing violence symptoms, 36.10% suffered from avoidance, 47.40% from NACM, and 46.90% from hyperarousal, while 47.10% of participants met the PTSD criterion. Finally, 18.20% of participants were at risk for harmful alcohol use.

Additionally, the proportions of women at risk for ShSTB, MDDS, suffering-perpetrating intimate-interpersonal violence, and mental health symptoms were significantly higher than those of men (p <0.001). The proportions at risk for alcohol use were similar between participants by sex. There also were significant differences between the proportions of participants at risk in the three-year-cohort group for almost all the variables except depression (p <0.001). The trends would appear to have increased by the last cohort year of the pandemic: 20-year-olds in 2023. Depression symptoms remained stable across the three cohort years.

Insert Table 2 approximately here

3.3 Structural Equation Modeling

The overall resulting model is shown in Figure 1. As can be seen, for the three years of the pandemic, the model includes the following paths: from perpetrating intimate violence (PIV) to ShSTB (β_PIV,β_ShSTB = 0.137) and MDDS (β_PIV,β_MDDS = 0.084), from anxiety to ShSTB (β_GA, β_ShSTB = 0.591) and MDDS (β_GA,β_MDDS = 0.634), and from suffering intimate violence (SIV) to reexperiencing, avoidance, negative alterations in cognitions and mood (NACM), hyperarousal (β_SIV,β_Rex = 0.823, β_SIV, β_Avo = 0.830, β_SIV, β_NACM = 0.832, β_SIV, β_Hyp = 0.829, respectively), to depression, and anxiety (β_SIV, β_MDE = 0.180, and β_SIV, β_GA = 0.698, respectively), to harmful use of alcohol (β_SIV, β_Alc = 0.347), and perpetrating interpersonal and intimate violence (β_SIV, β_PIntV= 0.702, β_SIV, β_PIntPV = 0.665, respectively).

SIV was indirectly associated with ShSTB and MDDS through PIV, meaning that it is associated with ShSTB and MDDS: SIV–PIV–ShSTB and SIV–PIV–MDDS, given that GA is also related to ShSTB and MDDS. The model fit the data from 195 iterations with 246 parameters (X² [2,722] = 8,327.33, p <0.001). It yielded a CFI of 0.946, a TLI of 0.943, and an RMSEA of 0.029 [0.028–0.029]), using a mixture of continuous and categorical observed variables from the total sample. Appendix A shows factor loadings for the observed variables for each scale of the SEM. In all cases, factor loadings were greater than 0.300.

Insert Figure 1 approximately here

As can be seen in Table 3, the general pattern was replicated for women and 20-year-old participants in 2023. For women and the oldest cohort, SIV + PIV and Anxiety were therefore associated with ShSTB and MDDS symptoms, and SIV was strongly related to PTSD symptoms, anxiety, depression, harmful alcohol use, PIPV, and PIV. For men, SIV + PIV and anxiety were related to ShSTB, but only anxiety was associated with MDDS symptoms. For men, SIV was also associated with mental health symptoms, harmful alcohol use, and perpetrating interpersonal-intimate violence. For the two younger cohorts, anxiety was the variable related to ShSTB and MDDS symptoms. At the same time, SIV was associated with mental health symptoms, harmful alcohol use, and perpetrating interpersonal-intimate violence. All models obtained CFIs and TLIs over 0.949, RMSEAs, and upper confidence intervals under 0.027.

Insert Table 3 approximately here

The results, therefore, suggest the dimensionality for all scales, as well as upward trends in perpetrating-suffering interpersonal-intimate violence, ShSTB, MDDS, mental health symptomatology, and harmful alcohol use throughout the cohort years during the pandemic, all moderated by sex. We have evidence that perpetrating intimate violence and anxiety were related to ShSTB and MDDS (Ha1 and Ha4) for women, and in the last cohort year, SIV indirectly by PIV was also associated with ShSTB and MDDS (Ha2) for women and in the last cohort year. PIV and, indirectly, SIV were exclusively related to ShSTB for men (Ha1 – Ha2). SIV was associated with PTSD symptoms (Ha5), depression (Ha3), anxiety (Ha4), harmful alcohol use (Ha6), and perpetrating interpersonal-intimate violence for all participants.

The present study shows the trends and relationship directionality between perpetrating-suffering intimate violence and ShSTB, MDDS, as well as the association between suffering intimate violence and mental health conditions and harmful use of alcohol among Mexican young adults during the COVID-19 pandemic. Findings suggest an upward trend in self-harm-suicide, violence, mental health symptoms, and harmful alcohol use in young Mexicans in 2021, 2022, and 2023. They mainly indicate that women and 20-year-old Mexicans who perpetratedintimate violence after suffering intimate violence and anxiety symptoms experienced self-harm-suicide warning signs and MDDS. Suffering intimate violence is also associated with PTSD, depression, anxiety symptoms, harmful alcohol use, and perpetrating violence. These patterns varied for men and younger cohorts. In particular, men who also reported perpetrating intimate violence after suffering intimate violence and suffering anxiety symptoms experienced self-harm-suicide warning signs.

The proportions of young people perpetrating intimate violence were slightly higher than what our previous longitudinal cohort study suggested in 2024. We also observed asymmetries by sex for mental health conditions as well as upward trends, except for depression, which remained high and stable during the pandemic for the entire youth sample [7; 1; 4]. Given that harmful alcohol use is a key condition associated with self-harm-suicide and violence, our findings suggested an increasing tendency among Mexican youth to report harm due to the use of this substance, with similar rates between Mexican men and women. Incidence of alcohol use was similar to what INPRFM [10], and our previous study indicated [6].

According to our hypothesis, findings thus suggest an associative pattern where perpetrating intimate violence, preceded by suffering intimate violence as well as anxiety symptoms, were associated with ShSTB and MDDS symptoms. However, the relationship was stronger in women and 20-year-old Mexicans. Among young Mexican men, the association between perpetrating intimate violence preceded by suffering violence and anxiety was exclusively associated with ShSTB warning signs. In addition, suffering intimate violence has been related to mental health symptoms such as depression, anxiety, and PTSD symptoms, as well as harmful alcohol use.

The central findings of PIV-SIV-GA associated with ShSTB and MDDS agree with previous ones reported by Kafka et al. [13], which conclude that intimate violence may be a precipitating factor for suicide risk. Kafka et al. [13] concluded that a high proportion of decedents had perpetrated nonfatal intimate personal violence prior to their suicide. Our secondary proved hypothesis, in which SIV is associated with mental health and alcohol use, is also similar to what Kafka et al. [13] suggested about intimate violence being common in younger participants who also use alcohol and to our previous findings about SIV associated with depression, anxiety, PTSD symptoms and harmful use of alcohol [6].

As Rooney et al. [11] suggested, in the current study, it appears we examined the association between perpetrating-suffering violence and self-harm-suicide thoughts and behaviors among Mexicans at the time of the evaluation. Nevertheless, instead of stepwise hierarchical regression, we used SEM analysis to examine these associations. Our model, therefore, suggested that the perpetration of violence was associated with ShSTB for the young Mexican people in our sample who experienced victimization, also supporting Rooney et al.’s [11] conclusions about the interaction between violent victimization and perpetration associated with ShSTB, even after accounting for sex, gender, mental health symptoms, and alcohol use.

Rooney et al. [11] suggested that separate processes contribute to suicide ideation and suicide attempts. They proposed that ideation-to-action frameworks could pinpoint the role of the acquired capability for suicide in the process of engaging in suicide behavior. They describe how painful or provocative experiences drive increases in pain tolerance and fearlessness of death, which contribute to the acquired capability for suicide, as Van Orden et al. also posited [34]. As all these authors have suggested, future studies should consider that violence victimization may be associated with increased pain tolerance. In contrast, violence perpetration may be associated with a decreased fear of death–an increased willingness to engage in self-directed violent acts. Morales-Chainé, Palafox, et al. [3] suggested distinguishing suffering from marked distress, dysfunction, somatization, and anxious depression from conditions where only the participants suffer from depression to prevent suicidal thoughts and behaviors. Moreover, current findings seem to suggest that previous experiences of suffering could interact with perpetrating intimate violence to explain reported ShSTB in both men and women and MDDS in women and 20-year-old participants.

Zuromski et al. [35] suggested that repeated victimization-intimate violence is followed by a traumatic stress response (such as reexperiencing, intrusive cognitions, avoidance, or numbing) and that it may serve to habituate adolescents to pain, increasing their acquired capability and accounting for the association between victimization and suicide attempts. Dewar et al. [36] also reported that perpetrators used nonfatal suicidal behaviors as a coping strategy to deal with overwhelming negative emotions, particularly in response to relationship stressors. Participants in our study reported this type of mental health symptoms associated with suffering intimate violence. It is, therefore, essential to continue exploring how mental health symptoms interact with perpetrating-suffering intimate violence to increase this proposed capability due to increased pain tolerance or a reduced fear of death in future research.

Meanwhile, Rooney et al. [11] have already suggested that repeated experiences of perpetration may result, for example, in decreased fear of death in the face of physical danger–signaling an increase in the acquired capability for suicide. A history of violent perpetration and victimization could indicate that the young participants in this study have an increased capability for self-harm-suicide thoughts and behaviors. However, it is essential to determine whether young Mexicans displaying an increase in marked distress, dysfunction, and somatization symptoms have greater pain tolerance or a reduced fear of death due to their acquired capability for perpetrating intimate violence after suffering intimate violence. There is a need to confirm these conditions and their relationship with the ShSTB warning signs in clinical studies and with men, women, and 20-year-old participants.

The Three-Step Theory (3ST; [37]) posits that ShSTB develops in the presence of every day pain (such as emotional pain) connected with lack of hope in life. The second step is the development of severe ideation, when the pain becomes higher than the sense of connectedness. At the end, the theory emphasizes the capability for suicide as a component of the intent to die. The capability for suicide is characterized by the habituation to the fear of death aroused by suicide ideation. The exposition to factors associated with suicide behavior may facilitate the development of suicide capability and help us identify effective mechanisms for prevention and intervention on the suicide behavior matters.

We sought to measure ShSTB, MDDS, perpetrating-suffering intimate-interpersonal violence, depression, anxiety, PTSD symptoms, and harmful alcohol use in young Mexican adults during the COVID-19 pandemic. In our study, ShSTB and MDDS symptoms were conceptualized in the mhGAP model of WHO (1). Perpetrating-suffering intimate-interpersonal violence was also conceptualized in the theoretical models of Oram et al. [38], Alexander and Johnson [39], Kourti et al. [40], Scott-Storey et al. [41], Weathers et al. [21], and Morales-Chainé et al. [24]. Depression, anxiety, PTSD symptoms, and harmful alcohol use were evaluated using the criteria of American Psychiatric Association [23], Goldberg et al. [27], Blevins et al. [26], and WHO [28], respectively.

In the context of valid measurements, our findings suggest trends and relationship directionalities between ShSTB, MDDS, violence, mental health, and alcohol use for a group of young Mexicans during the pandemic. We observed increased reports of self-harm, suicide risks, MDDS, perpetrating-suffering intimate-interpersonal violence, anxiety, PTSD symptoms, and alcohol use in youth aged from 18 in 2021 to 20 in 2023 at the end of the pandemic. By then, nearly one in two youths had suffered from ShSTB or MDDS symptoms. At the same time, findings showed that one in five women had perpetrated intimate violence. In comparison, one in two women had experienced intrafamilial violence as compared to one in three men [6]. Moreover, 65.20% of the women had also suffered interpersonal violence as opposed to 52.10 of men. Our findings also suggest that ShSTB and MDDS, as well as suffering intimate and interpersonal violence, had increased by the end of the pandemic among the group of young people in our study.

Intimate violence precedes a significant proportion of ShSTB and MDDS, pointing to clear opportunities for intervention. It is essential to identify abusive partner-threatening suicide planning not only to ensure the safety of the victim of intimate-personal violence but also to prevent the perpetrator’s suicidal behavior from emerging as a result of these social conditions. Considering trauma-informed approaches for intervention programs integrating suicide prevention efforts could increase the effectiveness of these programs while encouraging people who is perpetrating intimate-personal violence to seek treatment [42]. Developing screening and early intervention for intimate-personal-violence and suicide thoughts and behaviors mediated by sex could help prevent socially tough outcomes. We may provide training on assessment and early treatment of self-harm and suicide to those professionals that work with clients who suffer received or perpetrated violence.

4.1 Conclusions

Our study shows the trends and relationship directionality between perpetrating-suffering intimate violence and ShSTB and MDDS, as well as the suffering of intimate violence associated with mental health conditions and harmful use of alcohol among young Mexican adults during the COVID-19 pandemic. Findings suggest upward trends in ShSTB, MDDS, violence, mental health symptoms, and harmful use of alcohol in very young Mexicans in 2021, 2022, and 2023. Nearly one in two youths suffered from ShSTB or MDDS symptoms. Moreover, one in five women have perpetrated intimate violence, while one in two women have experienced intimate violence as compared with one in three men. Self-harm-suicide, marked distress, dysfunction, and somatization symptoms, as well as suffering intimate and interpersonal violence, appeared to increase by the end of the pandemic among Mexican youth. We also observed asymmetries by sex for mental health conditions as well as growing trends, except for depression, which remained high and stable during the pandemic, for the all-young sample. Our findings also suggest an increasing tendency among Mexican youth to report harm due to the use of this substance, with similar rates between young Mexican men and women.

Our study suggests an associative pattern where perpetrating intimate violence, preceded by suffering intimate violence combined with suffering anxiety symptoms were associated with ShSTB and MDDS. Nevertheless, the relationship was stronger in women and 20-year-old Mexicans. Among the young men in our sample, the relationship between perpetrating intimate violence preceded by suffering violence and anxiety was exclusively associated with ShSTB. Moreover, suffering from intimate violence has been related to mental health symptoms such as depression, anxiety, and PTSD symptoms, as well as harmful alcohol use. Future research could explore whether young Mexicans displaying increased MDDS symptoms have increased pain tolerance or a reduced fear of death regarding their acquired capability for perpetrating intimate violence after suffering intimate violence. Confirming these conditions and their relationship with ShSTB in clinical studies and with men, women, and 20-year-old participants is essential.

Future research could study the mechanisms explaining how perpetrating-suffering violence is related to the capability of suicide behaviors and how MDDS symptoms increase tolerance of pain or reduce the fear of death. It would also be helpful to study mechanisms to reduce the ascending trend in ShSTB and perpetrating-suffering intimate violence in Mexico. We should promote adopting evidence-based interventions for self-harm and suicide while addressing perpetrating intimate violence at the community level. It could reduce the intervention gap making available specialized care services in Mexico.

Intimate violence leads to a significant proportion of self-harm/suicide risk, highlighting key opportunities for prevention. We need to seek participants who warn about ShSTB not only for the safety of the victims of intimate-personal violence but also to prevent the perpetrator’s suicidal behavior from materializing as a result of these social conditions. Findings in Mexican youth point to the need to design cost-effective perpetrating intimate violence interventions to prevent self-harm-suicide warning signs, marked distress, dysfunction, and somatization distinguishing between sex and age, as well as to eradicate suffering intimate violence, and reduce mental health problems and harmful alcohol use, as a public health policy for future pandemics. It is essential to design cost-effective intimate violence interventions to prevent ShSTB, MDDS, depression, anxiety, and harmful alcohol use, incorporating them into public health policy for future pandemics.

4.2 Limitations

This is a longitudinal cohort study based solely on youth reports of ShSTB, MDDS, violence, mental health symptomatology, and harmful alcohol use. It has limitations in regard to the need to include older youth while determining the policies and community interventions that should be implemented in Mexico. Future studies could also undertake sensitivity and specificity evaluation research on the validity of our scales. Some sensitivity and specificity analysis of our anxiety scale based on Goldberg et al. [27] was undertaken. However, verifying these psychometric assessment characteristics during the pandemic would help solve their common limitations. This would prevent the overestimation of symptoms and reports while replicating the models obtained.

Conflict of interest The authors declare that the research was conducted without commercial or financial relationships that could create a conflict of interest.

Funding We are grateful to the National Autonomous University of Mexico for its support with the key DGAPA-IV300121.

Informed consent statement Informed consent was obtained from all subjects involved in the study.

Author contributions Silvia Morales-Chainé, Gonzalo Bacigalupe, Rebeca Robles-García, Alma Luisa López-Fuentes, and Violeta Félix-Romero contributed to the conceptualization, writing, data analysis, discussion, and data interpretation. All authors contributed to the article and approved the submitted version.

Data Availability Statement. The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

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Table 1 Proportions by Sex and Cohort Years

Sex	18-years 2021		19-years 2022		20-years 2023		Total
Sex	n	%	n	%	n	%	n	%
Men	695	50	327	50	221	50	1243	50
Women	695	50	327	50	221	50	1243	50
Total	1390	55.91	654	26.31	442	17.78	2486	100

Table 2 Distribution of Participants at Risk for Self-harm-suicide, Violence, Depression, Anxiety, PTSD Symptoms, and Harmful Alcohol Use for the Total Sample by Sex and Cohort


ShSTB												MDDS
Total		Men		Women**		2021		2022		2023**		Total		Men		Women**		2021		2022		2023**
n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
946	38.10	362	29.10	584	47.00	500	36.00	223	34.10	223	50.50	995	40.00	392	31.50	603	48.50	542	39.00	227	34.70	226	51.10
Suffering Intimate Violence												Suffering Interpersonal Violence
Total		Men		Women**		2021		2022		2023**		Total		Men		Women**		2021		2022		2023**
n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
938	37.70	356	28.60	582	46.80	475	34.20	245	37.50	218	49.30	1459	58.70	648	52.10	811	65.20	778	56.00	373	57.00	308	69.70
Perpetrating Intimate Violence												Perpetrating Interpersonal Violence
Total		Men		Women**		2021		2022		2023*		Total		Men		Women**		2021		2022		2023**
n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
475	19.10	180	14.50	295	23.70	267	19.20	106	16.20	102	23.10	809	32.50	361	29.00	448	36.00	412	29.60	196	30.00	201	45.50
Depression												Anxiety
Total		Men		Women**		2021		2022		2023		Total		Men		Women**		2021		2022		2023**
n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
1765	71.00	853	68.60	912	73.40	976	70.20	467	71.40	322	72.90	1183	47.60	454	36.50	729	58.60	615	44.20	299	45.70	269	60.90
Reexperiencing												Avoidance
Total		Men		Women**		2021		2022		2023**		Total		Men		Women**		2021		2022		2023**
n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
1072	43.10	423	34.00	649	52.20	523	37.60	285	43.60	264	59.70	897	36.10	342	27.50	555	44.70	437	31.40	231	35.30	229	51.80
NACM												Hyperarousal
Total		Men		Women**		2021		2022		2023**		Total		Men		Women**		2021		2022		2023**
n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
1178	47.40	469	37.70	709	57.00	590	42.40	308	47.10	280	63.30	1166	46.90	466	37.50	700	56.30	578	41.60	311	47.60	277	62.70
PTSD												Alcohol
Total		Men		Women**		2021		2022		2023**		Total		Men		Women		2021		2022		2023**
n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
619	47.10	223	40.90	396	51.40	293	44.30	152	43.20	174	57.60	453	18.20	236	19.00	217	17.50	186	13.40	142	21.70	125	28.30

Note. n.-number of participants; %.-percentage of participants; ShSTB.-current Self-harm and Suicide Thoughts and Behaviors; MDDS.-Marked Distress, Dysfunction, and Somatization; NACM-Negative Alterations in Cognitions and Mood; PTSD-post-traumatic stress disorder; * Significant differences between groups < 0.05. **Significant differences between groups < 0.001. At-risk group criteria were included in the instruments section. This means (1) a score over one for ShSTB, MDDS, suffering and perpetrating intimate and interpersonal violence is required to meet the criteria; (2) a score over 11 is required to meet the criteria for harmful alcohol use ; (3) criteria A and B for depression; (4) an average of over 60% for anxiety; (5) a two-response option or more is required for at least one of the B items, one of the C items, two of the D items, two of the E items, and bothersome symptoms for over a month for PTSD.

Table 3 Variables from SEMs with Their Path Coefficients (β) and Standard Errors (e) by Sex and Cohort Year

Predicted Variables	Men		Women		18-year 2021		19-year 2022		20-year 2023
	n=1,243		n=1,243		n=1,390		n=654		n=442
	β=	e=	β =	e=	β =	e=	β =	e=	β =	e=
PIV
ShSTB	0.254	0.147	0.332	0.103					0.269	0.07
MDDS			0.262	0.107					0.172	0.08
Anxiety
ShSTB	0.489	0.019	0.410	0.014	0.681	0.021	0.596	0.028	0.460	0.020
MDDS	0.571	0.018	0.472	0.015	0.732	0.022	0.633	0.028	0.504	0.022
SIV
Reexperiencing	0.837	0.099	0.901	0.109	0.848	0.082	0.881	0.150	0.834	0.191
Avoidance	0.843	0.104	0.902	0.110	0.856	0.083	0.881	0.155	0.834	0.208
NACM	0.837	0.088	0.917	0.085	0.859	0.061	0.886	0.120	0.854	0.190
Hyperarousal	0.842	0.129	0.907	0.152	0.849	0.122	0.893	0.194	0.851	0.250
Depression	0.177	0.069	0.153	0.049	0.207	0.051	0.146	0.083	0.155	0.081
Anxiety	0.709	0.240	0.582	0.183	0.741	0.214	0.729	0.295	0.564	0.323
Depression~ ~Anxiety	0.389	0.162	0.281	0.099	0.382	0.134	0.414	0.195	0.354	0.158
Alcohol	0.403	0.063	0.376	0.054	0.360	0.047	0.347	0.036	0.283	0.091
PIPV	0.624	0.069	0.776	0.050	0.771	0.048	0.888	0.078	0.697	0.100
PIV	0.896	0.074	0.802	0.053	0.682	0.050	0.603	0.093	0.653	0.117
PIPV~ ~PIV	0.141	0.096	0.855	0.031	0.854	0.036	0.851	0.064	0.586	0.063
Model
X²	4067.41		5274.5		4817.393		3552.16		3449.83
df	2503		2722		2575		2575		2722
p≤	0.001		0.001		0.001		0.001		0.001
RMSEA	0.022		0.027		0.025		0.024		0.025
Confidence Interval	0.021-0.024		0.026-0.029		0.024-0.026		0.022-0.026		0.022-0.027
CFI	0.965		0.952		0.958		0.973		0.961
TLI	0.964		0.949		0.956		0.971		0.959

Note. n.- number of participants; ShSTB-current Self-harm and Suicide Thoughts and Behaviors; MDDS - Marked Distress, Dysfunction, and Somatization; SIV- Suffering Intimate Violence; PIV-Perpetrating Intimate Violence; PIPV-Perpetrating Interpersonal Violence; NACM-Negative Alterations in Cognitions and Mood

No competing interests reported.

AppendixA.docx

Perpetrating-Suffering Intimate Violence: Self-Harm-Suicide Thoughts and Behaviors, Mental Health, and Alcohol Use among Mexican Youth during COVID-19

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

1 Background

2 Methods

2.1 Participants and design

2.2 Instruments

2.3 Data Analysis

3 Results

4. Discussion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1