Background:Major depressive disorder affects over 280 million people worldwide, and access to effective treatment remains limited. Transcranial direct current stimulation (tDCS) is a noninvasive option, and portable devices now allow for home-based delivery under varying degrees of remote supervision. Objective:This study aimed to systematically review and meta-analyze the efficacy, safety, feasibility, and acceptability of home-based and remotely supervised tDCS for depressive disorders. Methods:Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 and PRISMA-S (Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension) guidelines, we searched MEDLINE, Embase, Web of Science, the Cochrane databases, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform up to July 2025, with backward and forward citation searching. Two reviewers independently screened records, extracted data, and assessed risk of bias (version 2 of the Cochrane risk-of-bias tool for randomized trials, Newcastle-Ottawa Scale for observational studies, and Critical Appraisal Skills Programme for qualitative studies) and certainty of evidence (Grading of Recommendations Assessment, Development, and Evaluation; GRADE). Results:This review included 12 distinct studies (16 reports), of which 6 (50%) were randomized sham-controlled trials forming the meta-analytic pool. Active home-based tDCS produced a small, statistically significant improvement over sham (pooled Hedges g=0.36, 95% CI 0.06-0.66; P=.03; I2=34.3%). The effect was not robust to removal of the single largest positive trial (omitting the one study from 2025: g=0.39, 95% CI -0.12 to 0.91), and trial-level results were mixed: the 2 largest trials (one unsupervised [n=210] and one self-administered [n=141]) were negative on their primary depression outcomes, whereas the largest real-time supervised trial (n=174) was positive (between-group 95% CI 0.51-4.01; P=.01). This estimate was concordant in direction with an independent peer-reviewed meta-analysis of overlapping trials, which reported a pooled Montgomery-Åsberg Depression Rating Scale reduction (weighted mean difference -2.74, 95% CI -4.19 to -1.29) and Hamilton Depression Rating Scale reduction (weighted mean difference -2.24, 95% CI -4.16 to -1.49), attenuating to nonsignificance (P>.05) in major depressive disorder without comorbid cognitive impairment. The pooled effect fell at or near the minimal clinically important difference. GRADE certainty was moderate. Adverse events were predominantly mild: one pilot study was terminated early for skin lesions, and one nonfatal suicide attempt occurred in an unsupervised trial. Conclusions:Home-based and remotely supervised tDCS produces a small, statistically significant but clinically modest antidepressant effect that is sensitive to the inclusion of the largest positive trial, with the 2 largest trials being negative. The available controlled evidence does not establish supervision intensity as a determinant of efficacy. Current data are insufficient to recommend routine clinical adoption; adequately powered trials with standardized supervision and longer follow-up are needed.
Background:Long-term outcomes of intensive care unit (ICU) survivors remain a major public health concern. Despite the existence of a universal health care system in South Korea, socioeconomic and regional disparities may affect postcritical illness survival. Objective:In this nationwide cohort study, we aimed to examine the associations of socioeconomic and regional factors with long-term mortality among ICU survivors. Methods:We conducted a retrospective population-based cohort study using data from the Korean National Health Insurance Service (NHIS). We included adult patients (≥20 y) admitted to ICUs between 2015 and 2019 who survived to hospital discharge. Patients admitted for injury-related or external causes were excluded. Postdischarge socioeconomic status (SES) indicators included insurance type (National Health Insurance [NHI] vs Medical Aid [MA]), NHIS eligibility status, and income level quartiles. Residential area was analyzed separately as a regional contextual factor. The primary outcome was all-cause mortality for up to 8 years after discharge, which was estimated using the Kaplan-Meier method. Adjusted hazard ratios (aHRs) and 95% CIs were estimated using multivariable time-dependent Cox proportional hazards models stratified by age (20-39 y, 40-64 y, and ≥65 y). Results:Among 871,366 adult ICU survivors, 9.6% (n=83,766) were MA beneficiaries. Lower SES-defined by MA coverage, nonemployee NHIS eligibility categories, and lower income level-was consistently associated with higher long-term mortality. Compared with NHI enrollees, MA recipients had an aHR of 1.63 (95% CI 1.60-1.66) among middle-aged adults and 1.48 (95% CI 1.38-1.60) among younger adults. Dependents and self-employed insured household members had 2-fold to 3-fold higher mortality risk than employee-insured beneficiaries. A stepwise income-mortality gradient was evident across all age groups. Residence in other regions was also associated with higher mortality (aHR 1.06-1.11). Younger individuals were particularly vulnerable to SES-related disparities. Conclusions:Despite South Korea's universal insurance system, socioeconomic and regional disparities in long-term mortality persist among ICU survivors. Ensuring equitable access to post-ICU care, income security, and targeted social support may help promote sustainable recovery.
Unlabelled:Powered air-purifying respirators (PAPRs) are respiratory protective devices that actively supply filtered air and maintain positive pressure in the breathing zone, thereby limiting the inward leakage of unfiltered ambient air through gaps. Their principles and technology are already established. Positive-pressure PAPRs have primarily been used by health care workers in high-risk environments. However, their potential as an individual-level infection-control measure applicable to the general public has not been formally positioned for evaluation within the context of pandemic preparedness. This viewpoint aims to demonstrate the rationale for and need to position exposure control using positive-pressure PAPRs designed for the general public as a subject of systematic public health evaluation. Unlike existing measures that depend primarily on behavioral change, spatial separation, or acquisition of immunity, this intervention directly reduces aerosol inhalation exposure in an individual's breathing zone-the physical process that precedes airborne infection. Existing engineering studies increasingly make it possible to consider a public-oriented positive-pressure PAPR not merely as an idea but as a concrete intervention model with the potential for manufacture and implementation. However, the extent to which engineering measures of aerosol protection translate into individual-level prevention of infection and population-level infection control under real-world conditions must be established empirically. Individual-level preventive effectiveness, population-level infection-control effectiveness, engineering performance, feasibility of implementation, sustained use, social acceptability, cost, and equity must therefore be evaluated comprehensively by integrating medical and engineering assessments within a public health framework. This article does not advocate the immediate introduction of positive-pressure PAPRs for the general public. Rather, it identifies an institutional gap: established principles and technologies have not been incorporated into formal public health evaluation as a population-level infection-control measure. Evaluating positive-pressure exposure control for the general public is necessary to determine whether it could broaden policy options in future respiratory infectious disease pandemics and reduce excessive reliance on measures with major societal consequences.
Background:Mental health chatbots are increasingly used to support people with depressive symptoms, and large language models make these systems more flexible than rule-based chatbots. However, it remains unclear how well large language model-based chatbots deliver structured psychological interventions. Objective:This study examined how well a GPT-4o-based chatbot delivered a behavioral activation intervention for young people with depression using sessions with artificial users and clinical expert assessment. It also identified limitations and potential refinements. Methods:We implemented a GPT-4o (gpt-4o-2024-08-06; OpenAI)-based chatbot using a structured system prompt to deliver a single-session behavioral activation intervention for people with depression aged 14 to 29 years. We generated 48 sessions with GPT-4o-based artificial users derived from clinical vignettes varying across 7 characteristics. Ten clinical experts, either licensed psychotherapists or advanced psychotherapy trainees, independently assessed the sessions using the 14-item Quality of Behavioral Activation Scale (Q-BAS), rated from 0 to 6, supplemented by rating therapeutic capabilities, artificial user authenticity and difficulty, and qualitative feedback. Results:The chatbot completed all 7 intervention phases in every session. The mean holistic session quality rating was 3.94 (SD 1.23), and the mean Q-BAS rating was 4.03 (SD 1.18). Thirteen of 14 Q-BAS components exceeded the satisfactory threshold of 3. Ratings were highest for mood assessment (mean 5.42, SD 1.09) and activity planning (mean 4.98, SD 1.41) and lowest for explaining positive reinforcement (mean 2.92, SD 2.30) and supporting activity-mood monitoring (mean 3.02, SD 2.04). Therapeutic capability ratings were highest for message safety (mean 5.90, SD 0.37), message clarity (mean 5.56, SD 0.77), and objective, nonjudgmental communication (mean 5.17, SD 1.04) and lowest for therapeutic rapport (mean 4.12, SD 1.45) and natural conversation flow (mean 4.25, SD 1.42). Artificial users were rated below the scale midpoint for authenticity (mean 2.75, SD 1.41) and difficulty (mean 1.23, SD 1.46). Clinical experts described the chatbot as structured, clear, and safe but identified insufficient clinical reasoning as the main limitation, particularly in evaluating the therapeutic suitability and feasibility of activities, barriers, solution strategies, and rewards. Artificial users were often highly compliant, especially when identifying positive activities. Conclusions:In expert-rated sessions with artificial users, the chatbot delivered the behavioral activation intervention as intended and performed strongest on procedural components. It performed less well on positive reinforcement and activity-mood monitoring, indicating refinement needs in clinical reasoning, follow-up questioning, and evaluating whether proposed activities, plans, barriers, solution strategies, and rewards are therapeutically appropriate and feasible. The findings identify targets for improvement before testing with human users, while the artificial user design and expert ratings limit conclusions about real therapeutic interactions.
Background:Suicide remains a leading cause of death among young adults aged 18 to 25 years. Young adults experiencing suicidal ideation (SI) are increasingly using crisis text services (CTSs), a free and accessible option for crisis intervention. Little is known about CTSs from the young adult perspective. Objective:This study aimed to characterize young adults' experiences with and perceptions of CTSs for SI. Methods:We conducted in-depth interviews, by phone, Zoom, or text, with young adults (n=39) in the United States who had a lifetime history of SI. Participants included those who had or had not engaged with CTSs for SI. Semistructured interviews were conducted from January to July 2024. The data were analyzed using a modified grounded theory approach. Results:We constructed 5 key themes to characterize young adults' perceptions of and experiences with CTSs for SI. Young adults perceived CTSs as a unique component of their mental health crisis management. They appreciated CTSs' technological features, particularly the privacy they provided and the ability to reflect on and edit responses. However, they expressed dissatisfaction with the nonspecific nature of many CTS interactions. The perceived anonymity of CTSs served multiple functions, both as a motivator for CTS use and as a potential point of vulnerability, should it be lost during a CTS interaction. Participants' perceptions of CTSs' impact varied; some viewed them as beneficial, whereas others reported neutral or inconsistent effects over time. Conclusions:Among young adults with SI, CTSs are a key yet imperfect resource. Quality improvement and evaluation efforts may be needed to understand how responders can better tailor responses to improve conversational quality and consistency for young adult texters.
Background:Bacterial gastroenteritis remains a substantial public health burden. South Korea has operated an electronic sentinel surveillance system (SSS) since 2000; in 2023, a total of 211 sentinel hospitals conducted surveillance for 11 notifiable types of bacterial gastroenteritis. The system has not undergone a comprehensive evaluation. Objective:This study evaluated the SSS's operational performance and reporting completeness, assessed the population-based geographic allocation of sentinel sites, and explored concordance between SSS reports and National Health Insurance (NHI) claim records. Methods:We conducted a mixed methods evaluation using a 2024 survey of staff at the 211 sentinel hospitals, an interview with the Korea Disease Control and Prevention Agency (KDCA) operator, KDCA operational reporting records, nationwide NHI claim records, and regional population statistics. The primary evaluation year was 2023; 2021 was a nonconsecutive descriptive comparator because these were the 2 complete annual extracts available in the analytic dataset. We calculated delayed reporting, submission completeness, and on-time completeness. Exploratory Pearson correlations compared paired weekly all-pathogen totals (52 weeks per year), annual surveillance target, and diagnosis code category counts within each age group (11 paired categories), and actual vs population-proportional sentinel allocations across 17 regions. Results:Of 211 sentinel hospitals, 180 (85.3%) responded. In total, 90% (162/180) rated reporting as simple or adequate; responses on goal awareness and overall satisfaction were predominantly neutral. The delayed reporting proportion was 2.4% (255/10,652) in 2021 and 1.1% (122/10,972) in 2023; submission completeness was 99.9% (10,652/10,660) and 100% (10,972/10,972), respectively; and on-time completeness was 97.5% (10,397/10,660) and 98.9% (10,850/10,972), respectively. The exploratory weekly SSS-NHI correlation was 0.899 in 2021 and 0.937 in 2023. Age-stratified annual cross-category correlations ranged from 0.665 to 0.969 in 2021 and from 0.939 to 0.983 in 2023. Correlations between actual and population-proportional sentinel allocations were 0.946 in 2021 and 0.951 in 2023. Conclusions:The SSS demonstrated favorable operational performance, with low reporting delay and near-complete submission. The claim comparison showed strong ecological comovement but cannot establish sensitivity or diagnostic equivalence because the data sources use different case definitions and counting units. Priorities are clearer communication of operational goals, standardized operator training, and future validation using patient- or episode-level data linked to laboratory results.
BACKGROUND:Prolonged sitting is an increasingly important public health concern, particularly in occupations that offer few opportunities for conventional exercise. Zero-time exercise (ZTEx) integrates brief muscle-engaging movements into daily routines without requiring dedicated time or equipment and may offer a practical way to interrupt prolonged sitting. However, the motivational, cognitive, and contextual factors associated with intention relevant to ZTEx adoption remain poorly understood. OBJECTIVE:This study examined the association between exercise motivation and general sedentary behavior reduction intention, used as a zero-time exercise-related intention proxy (ZTEx-IP), and assessed model-implied indirect associations involving general self-efficacy and perceived physical activity triggers among Chinese adults in sedentary occupations. METHODS:This cross-sectional survey included 790 adults working full-time in sedentary occupations across 20 provincial-level administrative divisions in China between May and September 2025. Eligible participants reported at least 6 hours of work-related sitting on a typical workday. Standardized questionnaires assessed exercise motivation, general self-efficacy, perceived physical activity triggers, and the ZTEx-IP. Multivariable regression and restricted cubic splines examined graded and nonlinear associations between exercise motivation and the ZTEx-IP. PROCESS Models 4 and 6 estimated covariate-adjusted direct and model-implied indirect associations using 5000 bootstrap resamples. RESULTS:Higher exercise motivation scores were associated with higher ZTEx-IP scores. Compared with participants in the lowest motivation tertile, those in the highest tertile had an adjusted score difference of 8.49 points (unstandardized regression coefficient, B=8.49, 95% CI 6.43-10.60; P<.001), and the association was nonlinear (P for nonlinearity<.001). In the prespecified ordered model, exercise motivation retained a direct association with the ZTEx-IP (B=0.167, 95% CI 0.088-0.246). Model-implied indirect associations were observed through general self-efficacy (B=0.104, 95% CI 0.057-0.155), perceived physical activity triggers (B=0.157, 95% CI 0.110-0.205), and their prespecified ordering (B=0.025, 95% CI 0.013-0.039). Perceived triggers accounted for a larger increment in explained variance than general self-efficacy (ΔR²=0.054 vs 0.033), and the adjusted outcome model explained 37.6% of the variance in ZTEx-IP scores (R²=0.376). CONCLUSIONS:Among Chinese adults in sedentary occupations, exercise motivation was positively associated with the ZTEx-IP, with model-implied indirect associations involving general self-efficacy and perceived physical activity triggers. The statistical ordering of these associations does not establish that the constructs develop sequentially over time. The comparatively larger trigger-related estimate identifies contextual cue salience as a candidate mechanism for prospective testing but does not demonstrate intervention effectiveness. These hypothesis-generating findings provide a basis for workplace trials of contextually adapted, multicomponent strategies that evaluate actual ZTEx frequency, objectively measured sitting interruptions, adherence over time, and workplace acceptability.
Background:Persecutory delusions have long mirrored prevailing cultural and technological concerns. Beliefs involving implanted devices, internet surveillance, hacked smartphones, algorithmic targeting, and AI-mediated control are increasingly visible in contemporary psychosis. However, we identified no prior review dedicated specifically to synthesizing technology-themed delusional content across historical and contemporary clinical contexts. Objective:This narrative review aimed to trace the historical evolution of technology-themed delusions, characterize their contemporary clinical phenomenology, examine relevant neurocognitive and sociocultural mechanisms, and discuss implications for psychiatric assessment and intervention. Methods:PubMed/MEDLINE, Scopus, and APA PsycInfo were searched without date restrictions, supplemented by backward citation tracking and targeted identification of historical primary sources. Eligible sources included original research, case reports and case series, reviews, and relevant conceptual or historical publications addressing delusional content involving technology. A narrative synthesis approach informed by the Scale for the Assessment of Narrative Review Articles (SANRA) framework was used. The final search was completed on May 1, 2026. Results:Forty-three sources were included in the narrative synthesis, comprising 9 case reports or case series, 14 empirical studies, 8 reviews, and 12 historical or conceptual sources. Technology-themed delusions appeared as pathoplastic variants of enduring persecutory, control, and referential motifs, clustering into 5 overlapping categories: surveillance and hacking beliefs, implant and control delusions, Truman Show-type broadcast phenomena, social media-specific referential ideas, and emerging algorithmic and AI-mediated themes. In the largest contemporary cohort (228 patients with psychosis), technology-themed delusions were described by 104 of the 201 (51.7%) patients with delusional thought content, and the odds of technology-themed delusions rose by approximately 15% per admission year (odds ratio 1.15, 95% CI 1.01-1.31; P=.04). Cognitive models of persecutory ideation, the aberrant salience hypothesis, technological unfamiliarity, digital immersion, and wider sociocultural narratives all appeared relevant to these presentations. Pandemic-era conspiracy material, including 5G and vaccine-microchip narratives, further illustrated how culturally available technological explanations may scaffold delusional elaboration in vulnerable individuals. Conclusions:Technology-themed delusions represent contemporary expressions of enduring delusional motifs shaped by digital culture. Their assessment requires psychiatric expertise combined with sufficient technological literacy to distinguish proportionate privacy concerns, overvalued conspiracy beliefs, and fixed delusional convictions. Future research should use prospective cohort designs, cross-cultural comparisons, and targeted evaluation of cognitive behavioral and digital literacy-informed interventions, while monitoring emerging AI-mediated phenomena.
Background:Digital mental health interventions using conversational AI agents are increasingly being adopted as scalable alternatives to traditional care. Engagement is typically measured using volume-based metrics (eg, session counts and total time on a platform). However, these metrics overlook engagement patterns over time, which are not well understood in relation to mental health outcomes. Objective:The purpose of this cross-sectional study was to explore how different patterns of engagement with Mental's AI conversational agent relate to self-reported depression and anxiety. We aimed to (1) identify and describe engagement profiles based on patterns of interaction depth and temporal consistency, (2) compare depression and anxiety symptoms across engagement profiles, and (3) explore whether engagement profiles were associated with mental health symptom severity. Methods:This cross-sectional observational study linked survey responses to back-end app usage data from 112 Mental app users who completed at least 5 sessions with the conversational AI agent. Engagement profiles were derived using median splits on interaction depth (α parameter) and temporal consistency (Gini coefficient). Depression was assessed using the Patient Health Questionnaire-8 (PHQ-8), and anxiety was assessed using the Generalized Anxiety Disorder-7 (GAD-7). One-way ANOVAs compared symptoms across profiles. Linear regression models examined associations between profiles and symptom severity, adjusting for age, gender, and total duration of use. Results:We identified 4 distinct engagement profiles based on interaction depth and temporal consistency: extended and episodic (profile 1; n=25), extended and consistent (profile 2; n=31), brief and episodic (profile 3; n=31), and brief and consistent (profile 4; n=25). Users in profile 1 (extended and episodic) reported the lowest anxiety (mean 2.68, SD 2.43) and depression (mean 3.48, SD 4.06), while profile 4 (brief and consistent) reported the highest anxiety (mean 10.00, SD 7.03) and depression (mean 10.60, SD 8.75). Significant differences were observed for anxiety (F3,108=8.07, P<.001, η²=0.18) and depression (F3,108=5.47, P=.002, η²=0.13). In adjusted models, engagement profile was significantly associated with depression (R²=0.16, F7,104=2.87, and P=.009) and anxiety (R²=0.21, F7,104=4.04, and P<.001). Compared to profile 1, users in profiles 2 and 4 reported significantly higher depression and anxiety. Profile 3 differed from profile 1 for anxiety only (β=3.11, P=.047). Conclusions:Users with longer, clustered sessions reported the lowest symptoms, whereas those with brief, evenly distributed use reported the highest symptom levels, suggesting that the structure of engagement may be associated with symptom levels in ways that aggregate usage metrics do not capture. These findings are preliminary and hypothesis-generating, highlighting the importance of considering how engagement unfolds over time and suggesting that pattern-based measurement may improve the understanding of user outcomes in AI-powered mental health care. Future work should examine the directionality of these associations and whether distinct engagement patterns reflect meaningfully different modes of interacting with AI-powered care.
BackgroundBlood exposure accidents (BEAs) remain a major occupational hazard for health care providers, particularly in low‑resource settings. Despite their preventable nature, BEAs continue to occur frequently due to gaps in compliance with standard precautions and limited institutional surveillance. ObjectiveThis study aimed to determine the prevalence and factors associated with BEAs among health care providers in Kalemie, Tanganyika Province, Democratic Republic of the Congo. MethodsA cross-sectional study was conducted in March 2024 among 316 health care providers randomly selected from 34 health facilities: public facilities (20/34, 58.8%), private facilities (9/34, 26.5%), and faith‑based facilities (5/34, 14.7%). Data were collected using a structured questionnaire adapted from World Health Organization and Centers for Disease Control and Prevention tools. Logistic regression was performed to identify predictors of BEAs, with adjusted odds ratios (AORs), 95% CIs, and P values reported. ResultsThe lifetime prevalence of BEAs was 65.8% (208/316), and the 12-month prevalence was 60.4% (191/316). The most frequent causes were unexpected patient movement (81/191, 42.4%) and lack of attention (66/191, 34.6%). Needlestick injuries accounted for 59.2% (113/191) of exposures. Only 36.1% (69/191) of incidents were formally reported. Multivariate analysis identified two independent predictors: (1) noncompliance with standard precautions (AOR 2.921, 95% CI 1.503-5.677; P=.001) and (2) facility type (working in secondary‑level facilities was protective; AOR 0.310, 95% CI 0.144-0.670; P=.003). ConclusionsBEAs were highly prevalent among health care providers in Kalemie. Most incidents were preventable, and noncompliance with standard precautions significantly increased risk. Strengthening infection prevention and control measures, ensuring consistent availability of personal protective equipment, and establishing effective surveillance systems are urgently needed to protect health care workers and reinforce health system resilience.
Background:The burden of mental disorders is high in conflict-affected populations. In Palestine, we piloted Inuka Coaching, a digital intervention adapted from the Friendship Bench delivered by trained and supervised lay coaches. This paper documents the implementation of the intervention in this highly volatile context after October 7, 2023. Objective:This study aimed to describe the implementation of Inuka Coaching, a digital mental health tool based on task shifting, in Palestine and examine contextual challenges, fidelity to the coaching model, and lessons learned regarding recruitment, retention, and delivery during escalating ethnic cleansing. Methods:Two Palestinian mental health professionals were trained and certified in the Inuka method as head coaches, and subsequently trained 5 lay coaches. Palestinian adults in Gaza and the West Bank were recruited primarily through social media and received up to 4 structured, text-based coaching sessions typically delivered over 4 weeks depending on participant availability and preference. Standardized mental health screening questionnaires (Self-Reporting Questionnaire-20 [SRQ-20] and Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [PCL-5]) were collected at baseline, immediately after the first coaching session, and 3 months after the final session. Session transcripts were reviewed to assess coaches' fidelity to the Inuka method, and a focus group discussion explored coaches' experiences with training, delivery, and contextual challenges. Results:Between August 2023 and February 2024, a total of 70 participants were enrolled. Baseline assessments indicated high levels of psychological distress: 95.7% (67/70) scored above the PCL-5 threshold of 31, suggesting likely posttraumatic stress disorder, and 69.4% (43/62) scored in the "at risk" range on the SRQ-20. The effectiveness of the method could not be determined as retention was low, with only 7.1% (5/70) completing the program. Coach fidelity was high, with 94.6% (35/37) of transcripts adhering to all 5 steps of the intervention. Coaches reported positive experiences with the method but identified challenges related to recruitment, session continuity, platform usability, and the need for flexibility during acute crises. Key implementation learnings included the importance of early in-person collaboration and training, culturally sensitive framing, flexible delivery and session structures, and robust support for lay coaches. Conclusions:While digital, task-shifted mental health interventions can be delivered with fidelity in conflict settings, sustaining engagement during escalating violence remains challenging. Future implementations require flexible design, context-sensitive recruitment and retention strategies, adaptive delivery models, and strong support for lay coaches.
Background:The COVID-19 pandemic highlighted a critical need for effective population mental health approaches to target the most prevalent disorders (eg, depression) during periods of elevated community distress. The effectiveness of remotely delivered and web-based interventions should be investigated to identify and innovate high-quality models for population mental health service delivery. Objective:The primary objective investigated the effectiveness of adding Mindfulness-Based Cognitive Therapy for Resilience (MBCT-R)-a live, online, synchronous, remotely delivered, group-based intervention-to Cambridge Health Alliance MindWell (CHA-MW), a web-based population health screening and stratified support program, compared with CHA-MW alone, on depression symptom severity. The secondary objective evaluated adding internet Cognitive Behavioral Therapy (iCBT)-an asynchronous, web-based, individual, digital intervention-to CHA-MW, compared with CHA-MW alone. Methods:Participants (N=97) were randomized in a 2:2:1 ratio to receive MBCT-R+CHA-MW (n=37), iCBT+CHA-MW (n=41), or CHA-MW alone (n=19) in a 3-arm randomized clinical trial, from May 2021 to September 2022 in an urban public safety net hospital outpatient setting. CHA-MW served as a low-intensity control condition. For the MBCT-R+CHA-MW arm, MBCT-R was an 8-session program mildly adapted from MBCT to address COVID-19-related risks for depression. For the iCBT+CHA-MW arm, iCBT was a 6-session curriculum added to CHA-MW. All study procedures, including regular mental health symptom screenings, were conducted remotely or via a web-based platform. The primary outcome was change in depression symptom severity during the 24-week study period using an intention-to-treat approach that used generalized linear mixed-effects models to evaluate the comparative effectiveness of MBCT-R+CHA-MW vs CHA-MW over time. A secondary analysis compared iCBT+CHA-MW vs CHA-MW on depression severity. Completer analyses were conducted (per-protocol 6+ sessions). The secondary outcome was mental health visit utilization frequency during the study period. Results:Both MBCT-R+CHA-MW (mean difference -14.1, 95% CI -21.0 to -7.2) and CHA-MW (mean difference -15.2, 95% CI -21.8 to -8.6) had significant reductions in depression symptom severity, with no statistically significant between-group differences. iCBT+CHA-MW (mean difference -12.7, 95% CI -17.4 to -8.1) also reduced depression symptoms but without between-group differences when compared with CHA-MW. Intervention completion rates were low (MBCT-R: 30% and iCBT: 24%), and completers demonstrated significantly greater reductions in depression severity than noncompleters (mean difference -8.5, 95% CI -16.2 to -0.8). Overall mental health clinician visits by group had no statistically significant differences. CHA-MW had the largest increase in participants with new psychopharmacology treatment visits during the 24-week study (CHA-MW +21%, MBCT-R +10%, and iCBT -5%). Conclusions:MBCT-R+CHA-MW, iCBT+CHA-MW, and CHA-MW were each effective in treating depression, without any intervention demonstrating superiority in intention-to-treat analyses. CHA-MW was as efficacious during the COVID-19 pandemic as more resource-intensive interventions that demanded greater time and effort from participants. Low completion rates for MBCT-R and iCBT during the COVID-19 pandemic may have contributed to these results.
Background:Firearm mortality surveillance relies on aggregate demographic categories or low-dimensional stratifications, obscuring how race, ethnicity, sex, age, and intent intersect to shape risk among youth and young adults. The Centers for Disease Control and Prevention (CDC)'s transition to single-race population estimates created a structural break between historical and contemporary data series. Consequently, the 25-year trajectory of intersectional firearm mortality across changing federal classification frameworks remains uncharacterized. Objective:We aimed to characterize 25-year national trajectories in firearm homicide and suicide across intersecting domains of race or ethnicity, sex, age, and intent among US youth and young adults (aged 0-24 y), identifying specific sociodemographic groups experiencing the highest and most rapidly changing burdens. Methods:This study used the CDC WONDER Underlying Cause of Death database (25-year window from 1999-2024). To address the 2018 transition, a 2-period design was deployed: period 1 (1999 to 2020) used bridged 4-category race data, and period 2 (2018 to 2024) used 6-category single-race data. Crude death rates and disparity ratios (referenced to non-Hispanic White youth) were calculated using the Byar approximation. Average annual percentage changes (AAPCs) were modeled via log-linear regression. Analyses incorporated finalized 2024 CDC WONDER data in January 2026. Results:Among 200,704 firearm deaths among youth aged 0-24 years from 1999 to 2024, overall mortality declined through 2013, reversed in 2014, and rose 28.9% from 2019 to 2020. In 2024, the overall rate declined 12% from 2023 but remained above the 2019 prepandemic baseline. During 2018-2024, Black non-Hispanic male youth experienced the highest pooled firearm homicide rate (44.03 per 100,000; 95% CI 43.46-44.61), 23.8 times the rate among White non-Hispanic males. The annual rates within this cohort increased from 33.28 in 2018 to 53.75 in 2021 before declining to 37.06 in 2024 (AAPC, +2.4%; P=.56), while the Black-to-White disparity ratio widened from 19.3 to 24.4. Black non-Hispanic female youth had the highest female firearm homicide rate (6.03 per 100,000), exceeding male rates in 7 of 12 other demographic groups. American Indian or Alaska Native non-Hispanic male youth experienced the highest pooled firearm suicide rate (11.74 per 100,000). Firearm suicide increased significantly among Black non-Hispanic male youth (AAPC, +9.2%; 95% CI +3.2% to +15.4%; P=.01), with a substantial but nonsignificant upward trend among Black non-Hispanic female youth (AAPC, +11.7%; P=.08), while White non-Hispanic male rates remained stable (AAPC, -0.1%; P=.91). Consequently, the Black-to-White non-Hispanic male suicide rate ratio shifted from 0.67 in 2018 to 1.07 in 2024, marking the first time Black youth rates surpassed White youth rates in modern public health surveillance history. Conclusions:Firearm homicide and suicide among US youth exhibit distinct demographic concentration patterns that are systematically obscured by aggregated public health surveillance. Disaggregated surveillance remains imperative to design targeted prevention strategies.
Background:High suicide risk is observed after discharge among patients hospitalized with suicidal thoughts and behaviors. Suicidal ideation (SI) is a well-known precursor to suicide attempts (SAs) and suicide, and it is a central indicator of subjective distress. Objective:This study aimed to examine patient characteristics and predischarge symptoms that might (1) distinguish between participants with and without postdischarge SI, (2) predict peak SI frequency, and (3) predict the intensity and longitudinal trajectory of SI. Methods:Before discharge, patients hospitalized due to high suicide risk were screened for diagnosis (MINI 7.0.2 [Mini International Neuropsychiatric Interview] and SCID-5-PD [Structured Clinical Interview for DSM-5 Personality Disorders]), general symptom severity (Outcome Questionnaire-45 [OQ-45]), depression (Patient Health Questionnaire-9 [PHQ-9]), SI (Suicide Status Form-IV [SSF-IV] and Beck Scale for Suicide Ideation), and suicidal behaviors (Suicide Attempt Self-Injury Count). Twenty male and 16 female adult participants installed a mobile app on their smartphones and reported their level of SI on a 5-point Likert scale (1=not at all to 5=very much) 5 times per day for 10 days after discharge. Associations between baseline characteristics and postdischarge SI were analyzed using logistic regression, median regression, and mixed-effects linear regression. Results:SI was present in 49.2% (528/1073) of all completed surveys. Women reported SI more frequently than men (χ21=63.39; P=.001). No baseline variables differentiated participants who later did (28/36, 77.8%) and did not (8/36, 22.2%) report momentary SI after discharge. Participants hospitalized due to a high risk of suicide (12/36, 33.3%), compared with those hospitalized following an SA (24/36, 66.7%), reported SI more often (χ21=22.64; P=.001) and had a higher frequency of peak SI scores (β=17.74, 95% CI 8.56-26.91; P=.001). Moreover, the variation in the temporal trajectory of postdischarge SI was characterized by large differences between participants (intraclass correlation coefficient [ICC]=0.682), while the intensity of SI did not change over the 10-day period at the group level (β=0.03, 95% CI -0.01 to 0.06; P=.09). Predischarge scores on the SSF-IV chronic subscale, including hopelessness, self-hate, and psychological pain, predicted the intensity of SI after discharge (β=0.13, 95% CI 0.05-0.20; P=.002). No baseline variables predicted the trajectory of SI. Conclusions:SI after discharge was common, varied substantially between participants, and may be more prevalent than previously reported, particularly in groups with high morbidity and prior SAs. The SSF-IV may be a valuable tool for treatment planning and assessment during the inpatient stay.
Background:Social media influencers occupy a pervasive role in billions of users' daily digital lives, particularly among adolescents and young adults. Audiences develop parasocial engagement with these figures, including parasocial relationships (PSRs) and parasocial interactions (PSIs). Despite growing concern about their mental health implications, no prior meta-analysis has quantitatively synthesized this evidence. Objective:This systematic review and meta-analysis aimed to estimate the associations between influencer-directed parasocial engagement and mental health outcomes, examine prespecified moderators, and evaluate the quality of the existing evidence base. Methods:Seven databases (PsycINFO, Embase, MEDLINE, ERIC, PubMed, Web of Science, and Scopus) were searched from inception. Studies quantitatively assessing PSRs or PSIs with social media influencers and reporting mental health outcomes were eligible. A 3-level random-effects meta-analysis was conducted using Pearson r. Primary pooled estimates were calculated separately for positive or adaptive outcomes, and negative or maladaptive outcomes. Moderators examined included outcome domain, parasocial construct type, age group, gender, cultural region, and platform. Results:Seventeen studies (52 effect sizes) were included. Parasocial engagement was positively associated with both positive (k=28; r=0.38, 95% CI 0.18-0.55) and negative outcomes (k=24; r=0.24, 95% CI 0.08-0.38), with positive effects significantly stronger. Well-being showed the largest effects (r=0.42), followed by social media addiction (r=0.33). PSI demonstrated stronger associations than PSR (r=0.56 vs 0.22). Effects were largest among adolescents (r=0.44) and in Eastern samples (r=0.61 vs 0.29). No evidence of publication bias was detected (Egger P=.94; fail-safe N=18,643). Conclusions:Parasocial engagement functions as a psychological double-edged sword, reliably linked to both enhanced well-being and problematic engagement. Positive mental health outcomes, particularly those involving well-being, were generally stronger and more consistent than negative ones. These findings suggest that parasocial engagement should not be understood as uniformly beneficial or harmful; rather, its psychological meaning depends on the outcome domain, parasocial construct type, developmental stage, and cultural context. Future longitudinal, mechanism-based research with diverse samples is needed to clarify when parasocial engagement is most beneficial or harmful.
Background:On February 6, 2024, the Korean government announced an increase in medical school enrollment quotas, triggering a nationwide strike by medical residents that precipitated a severe health care crisis. Prehospital emergency medical service (EMS) providers were forced to transport patients to distant hospitals, resulting in some patients experiencing symptom deterioration or death due to delayed critical care. Recent studies have examined moral injury-a mental health response to events that undermine moral values-among EMS providers, with exposure to potentially morally injurious events increasing the likelihood of depression, anxiety, and posttraumatic stress disorder. However, studies specifically examining the association between health care-related patient deterioration experiences caused by health care service disruptions and mental health outcomes among EMS providers remain limited. Objective:This study evaluated the associations of patient deterioration due to health care service disruptions (hereafter referred to as health care-related patient deterioration experiences [HPDEs]) with burnout, depressive symptoms, and sleep problems among prehospital EMS providers during government-medical community disputes. Methods:We conducted a retrospective cross-sectional survey from November 1 to December 31, 2024, among EMS providers across South Korea using a web-based questionnaire. The independent variable was the presence or absence of HPDE, and the dependent variables were 3 mental health outcomes (personal burnout [PB], work-related burnout [WRB], and citizen-related burnout [CRB]), depressive symptoms, and sleep problems. χ2 tests and multivariable logistic regression were used to assess associations and identify influencing factors after adjustment for potential confounders. Results:Of 845 participants, 75% (n=626) reported HPDEs, which were associated with higher odds of PB, WRB, CRB, depressive symptoms, and sleep problems. Additionally, sex, age, educational attainment, and work region significantly influenced burnout, depressive symptoms, and sleep problems. Conclusions:During government-medical community disputes, EMS providers exposed to HPDEs-a form of potentially morally injurious event resulting from emergency medical resource shortages-had significantly elevated odds of burnout, depressive symptoms, and sleep problems. These findings underscore the urgent need for systematic psychological interventions and regular mental health screenings, such as for moral injury, to mitigate adverse mental health outcomes during future health care service disruptions.
Background: Men who have sex with men (MSM) constitute a significant proportion of individuals living with human immunodeficiency virus. Over the past few years, China has implemented various strategies aimed at increasing the rate of HIV testing and reducing HIV transmission among MSM. Among these, the disclosure of HIV serostatus is an effective prevention strategy. Objective: This study aimed to assess HIV serostatus disclosure and identify factors associated with awareness of sexual partners’ HIV status among MSM to provide a scientific basis for promoting HIV testing and reducing HIV transmission. Methods: A cross-sectional study based on a large-scale web-based survey was conducted among MSM in Zhejiang province, China, between July and December 2023. MSM who were HIV-negative or had an unknown HIV status were recruited from the Sunshine Test, a web-based platform that uses location-based services to provide HIV prevention services. Participants were required to complete a questionnaire on demographic characteristics, sexual behavior, rush popper use, awareness of sexual partners’ HIV status, and knowledge of pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP). A multinomial regression model was used to identify the factors associated with awareness of sexual partners’ HIV status. Results: A total of 7629 MSM participated in the study, with 45.2% (n=3451) being aware, 35.4% (n=2701) being partially aware, and 19.4% (n=1477) being unaware of their sexual partner’s HIV status. The multinomial logistic regression analysis revealed the following results. Compared to those who were unaware of their sexual partner’s HIV status, participants who were students (adjusted odds ratio [aOR] 1.43, 95% CI 1.09‐1.86), had a monthly income of more than US $1400 (aOR 1.36, 95% CI 1.03‐1.80), had insertive anal sex (aOR 1.35, 95% CI 1.12‐1.63), had only male sexual partners (aOR 1.53, 95% CI 1.28‐1.82), had 1 sexual partner in the past 3 months (aOR 2.36, 95% CI 2.01‐2.77), had used condoms for the past 3 months (aOR 1.72, 95% CI 1.33‐2.22), had frequently used rush poppers in the past 3 months (aOR 2.27, 95% CI 1.81‐2.86), were aware of HIV PrEP (aOR 2.04, 95% CI 1.68‐2.48), were aware of HIV PEP (aOR 1.69, 95% CI 1.39‐2.06), used mail reagent self-testing (aOR 1.19, 95% CI 1.04‐1.36), and had previously undergone HIV testing (aOR 1.40, 95% CI 1.16‐1.69) were associated with increased odds of being aware of their sexual partner’s HIV status. Conclusions: Overall, 45.2% of MSM who were HIV-negative or had an unknown status were aware of their sexual partners’ HIV status in China. We suggest strengthening targeted interventions through web-based platforms and gay apps to promote the disclosure of HIV serostatus and reduce HIV transmission among MSM.
