Abstract
BACKGROUND: Subclinical psychotic symptoms (SPS) are common among college students and can lead to future mental health issues. However, it is still not clear which specific childhood trauma, stressors and health factors lead to SPSs, partly due to confounding factors and multicollinearity. OBJECTIVE: To use machine learning to find the main predictors of SPS among university students, with special attention to gender differences. METHODS: A total of 21 208 university students were surveyed regarding SPS and a wide range of stress-related factors, including academic pressure, interpersonal difficulties and abuse. Nine machine learning models were used to predict SPS. We examined the relationship between SPS and individual stressors using χ(2) tests, multicollinearity analysis and Pearson heatmaps. Feature engineering, t-distributed stochastic neighborhood embedding (t-SNE) and Shapley Additive Explanation values helped identify the most important predictors. We also assessed calibration with calibration curves and Brier scores, and evaluated clinical usefulness with decision curve analysis (DCA) to provide a thorough assessment of the models. In addition, we validated this model using independent external data. FINDINGS: The Extreme Gradient Boosting (XGBoost) model had the best prediction results, with an Area Under the Curve (AUC) of 0.89, and validated with external data. It also showed good calibration, and DCA indicated clear clinical benefit. Interpersonal difficulties, academic pressure and emotional abuse emerged as the strongest predictors of SPS. Gender-stratified analyses revealed that academic pressure and emotional abuse affected males more, while health issues like chest pain and menstrual pain were stronger predictors for females. CONCLUSIONS: Machine learning models effectively identified key stressors associated with SPS in university students. These findings highlight the importance of gender-sensitive approaches for the early detection and prevention of psychotic symptoms. CLINICAL IMPLICATIONS: SPSs in college students can be predicted by interpersonal difficulties, academic stress and childhood emotional abuse. This information can help mental health professionals develop better ways to prevent and address SPSs.