OBJECTIVE:Despite over 10,000 mental health apps available, app marketplaces are unstable, characterized by high attrition rates and technological obsolescence. This study analyzed factors associated with app survival to help patients and clinicians in selecting more durable mental health apps and inform developers in creating more stable ones. METHODS:Using data from the M-Health Index and Navigation Database (MIND; MindApps.org), the authors performed a 5-year longitudinal survival analysis on 865 apps. App longevity was evaluated using Kaplan-Meier estimates, and Cox regression was used to assess the impact of 54 clinical, technical, and commercial predictors of attrition. Additionally, a random forest classifier was used to identify app characteristics associated with 2-year survival status. RESULTS:Of 865 apps identified, 464 (53.6%) were removed from MindApps.org during the 2,142-day study period. Disparities in longevity were observed across clinical targets; aside from the small cohort of apps for schizophrenia, smoking cessation apps presented the highest risk for attrition. Sleep-related apps demonstrated the greatest longevity. Cox regression (C-index=0.77) and an exploratory random forest analysis (area under the receiver operating characteristic curve=0.82) identified platform exclusivity (not working on both Android and iOS) as the most prominent characteristic associated with removal from MindApps.org, with Android-only apps exhibiting a significantly elevated risk, carrying more than double the hazard of attrition (Gini feature importance=0.12; hazard ratio=2.32). CONCLUSIONS:The findings provide a roadmap for identifying durable mental health apps, thereby minimizing the risk of treatment attrition. The predictors of removal from MindApps.org provide critical lessons for the new era of AI-based tools.
OBJECTIVE:Long-acting injectable antipsychotics (LAIAs) can improve adherence, but their optimal use in bipolar disorder needs to be further explored. This study compared LAIAs and oral antipsychotics with respect to health care utilization, illness relapse, and safety in individuals with bipolar disorder. METHODS:A self-controlled case series study was conducted using data from Hong Kong's electronic health records on individuals with bipolar disorder who received prescriptions for both LAIAs and oral antipsychotics during the period of January 1, 2004, through December 31, 2023. Outcomes included measures of health care utilization, illness relapse, and safety. Adjusted incidence rate ratios (aIRRs) for LAIA versus oral antipsychotic treatment periods were estimated using conditional Poisson regression. RESULTS:Among 17,841 people with bipolar disorder, 2,086 (11.7%) received prescriptions for both LAIAs and oral antipsychotics. Compared with oral antipsychotics, LAIAs were associated with statistically significantly lower risks of all-cause emergency department visits (aIRR=0.85, 95% CI=0.81, 0.89), all-cause hospitalizations (aIRR=0.79, 95% CI=0.73, 0.85), psychiatric hospitalizations (aIRR=0.67, 95% CI=0.61, 0.74), hospitalizations for manic episodes (aIRR=0.51, 95% CI=0.44, 0.59), and hospitalizations for mixed episodes (aIRR=0.31, 95% CI=0.14, 0.66). No statistically significant difference was found for hospitalizations for depressive episodes (aIRR=1.34, 95% CI=0.94, 1.93), nonpsychiatric hospitalizations (aIRR=0.97, 95% CI=0.87, 1.08), or cardiovascular hospitalizations (aIRR=0.84, 95% CI=0.62, 1.14). LAIAs were initially associated with an increased risk of extrapyramidal symptoms (aIRR=2.95, 95% CI=1.40, 6.22), but this difference was not statistically significant beyond 90 days of treatment. CONCLUSIONS:LAIAs were associated with substantially less health care utilization and fewer relapses of manic and mixed episodes, and they were not associated with increased risk of nonpsychiatric hospitalizations, notably for cardiovascular disease. These findings support the use of LAIAs for bipolar disorder, with close monitoring for extrapyramidal symptoms during initiation.
OBJECTIVE:Adverse childhood experiences (ACEs) play a pivotal role in alcohol use disorder (AUD), and evidence suggests that this role differs by sex. Neural alcohol cue reactivity may represent one pathway linking ACEs to alcohol craving and use. The authors examined whether cue reactivity is differentially associated with the relationship between ACEs and alcohol-related outcomes in males and females with AUD. METHODS:Functional MRI data were analyzed from 231 non-treatment-seeking individuals (40.7% female; mean age=39.1 years, SD=13.5) with mainly mild to moderate AUD (mean number of DSM-5 criteria, 3.92, SD=1.6) from a 12-month prospective multicenter study. ACEs were assessed via Childhood Trauma Screener score. Participants completed a functional MRI alcohol cue reactivity task, followed by ecological momentary assessment of daily craving and consumption. Linear regression, general linear models, and sex-moderated mediation examined associations among ACEs, brain activation, and alcohol outcomes. Sensitivity analyses controlled for age, AUD severity, baseline consumption, tobacco use, Brief Symptom Inventory score, and progesterone-to-estradiol ratio. RESULTS:Higher Childhood Trauma Screener scores were associated with significantly greater left superior frontal gyrus/anterior cingulate cortex (SFG/ACC) activation during alcohol-related cues than during neutral cues in females compared with males. This activation significantly predicted prospective daily craving only in females. Sex-moderated mediation showed opposing indirect effects of ACEs on craving via SFG/ACC activation (ab=path a × path b; females: ab=0.008, 95% CI=0.001, 0.022; males: ab=-0.013, 95% CI=-0.034, -0.002). Sensitivity analyses supported robust SFG/ACC activation and directional consistency after adjustment for covariates. CONCLUSIONS:Sex-specific prefrontal cue reactivity patterns suggest differential neural pathways linking ACEs to craving vulnerability in early AUD, particularly in females. The findings support sex-sensitive, trauma-informed intervention strategies.
