Despite most of the world's population having poor access to mental health services, scalable interventions delivered by trained non-specialists are implemented widely in low-income and middle-income countries (LMICs). Many people do not respond to these interventions, which has led to initiatives to adopt stepped care frameworks that provide people who do not respond to initial interventions with more intensive interventions. However, to date, the efficacy and cost-effectiveness of stepped care frameworks for scalable interventions have not been evaluated in LMICs. This trial aims to evaluate effectiveness and cost-effectiveness of psychological stepped care for distressed adults in an LMIC.

We did a single-blind, parallel, randomised controlled trial in Jordan with psychologically distressed adults who were randomly assigned (1:1) to a single intervention or stepped care model. Participants were required to be aged 18 years and older, Jordanians or refugees residing in Jordan, and have scores of at least 20 on the Kessler Distress Scale. Exclusion criteria were imminent suicide risk, psychotic disorder, severe cognitive impairment, risk to the person's safety, plan to return to Syria in the next 12 months, or no telephone access. Computerised software was used for randomisation to generate random number sequences in blocks of four, stratified according to nationality status by personnel independent of the trial. Assessors were masked to intervention condition. All participants received WHO's Doing What Matters in Time of Stress (DWM) programme, which comprised a five-session guided self-help programme. For participants who reported psychological distress after DWM, those in the single intervention group received enhanced usual care, whereas those in the stepped care group received WHO's Problem Management Plus, a five-session group psychological intervention. The primary outcome was between treatment group change in anxiety and depression severity assessed at 3 months after treatment (primary outcome timepoint) based on intention-to-treat analysis. Cost-effectiveness was also assessed. The trial was prospectively registered on the Australian New Zealand Clinical Trials Registry, ACTRN12621000189820, and is completed.

Between June 8 and Oct 8, 2023, 1233 individuals were screened for study inclusion and 432 were excluded (371 due to minimal distress, 30 due to a suicide risk, and 31 decided not to proceed), resulting in 801 participants being enrolled into the study. 400 participants were randomly assigned to the stepped care group and 401 were randomly assigned to the single intervention group. 753 participants were female (94%), 48 (6%) were male, and the mean age was 40·7 years (SD 11·1). At the 3-month assessment, participants enrolled in stepped care reported greater reduction of anxiety (mean difference 1·9 [95% CI 0·6-3·2; p=0·0030; effect size 0·3 [95% CI 0·1-0·5]) and depression (mean difference 2·9 [0·9-5·0]; p=0·0050; effect size 0·3 [0·1-0·5]) than participants in the single intervention group. The incremental cost per quality-adjusted life-year gained for stepped care (in international dollars [INT$]) would be INT$23 641 and has a 76% likelihood of being cost-effective at a threshold of INT$31 879 in Jordan.

Stepped care of WHO's evidence-based scalable interventions can provide greater benefits in reducing common mental disorders compared with a single intervention. Although a more resource-demanding treatment strategy, stepped care can be cost-effective in terms of its capacity for relatively greater improvements in mental health in LMICs.

Elrha through the Research for Health in Humanitarian Crises (R2HC) programme.

For the Arabic translation of the abstract see Supplementary Materials section.

Individuals with opioid use disorder (OUD) may experience fewer barriers to treatment following incarceration if offered in-jail medications for OUD (MOUD). We aimed to identify care trajectories of community OUD treatment after incarceration and examine the association between receiving in-jail MOUD and experiencing specific community treatment trajectories.

This retrospective cohort study using matched New York City (NYC) health care administrative data included adults with OUD incarcerated on or after May 2011 and discharged during 2014-2017. We defined states of community OUD treatment at the weekly level over one year following index jail discharge and performed state sequence analysis (SSA) to identify trajectories of treatment after jail and assessed the influence of receiving in-jail MOUD on treatment trajectories.

Of 14,923 eligible individuals, 26.2% received in-jail MOUD. SSA identified eight clusters of community care trajectories: continuous methadone treatment (9.7%), methadone treatment discontinuation (3.7%), methadone treatment and reincarceration (6.7%), methadone treatment initiation (4.8%), continuous reincarceration (3.5%), short reincarceration with little community treatment (20.3%), long reincarceration with little community treatment (7.0%), and no community OUD treatment or reincarceration (44.5%). Receiving in-jail MOUD was associated with belonging to the continuous methadone treatment cluster compared to the no community OUD treatment or reincarceration cluster (adjusted OR: 12.5, 95% CI: 9.9-15.7).

We identified eight unique patterns of community OUD treatment after jail release. Receipt of in-jail MOUD was associated with belonging to the continuous methadone treatment cluster. These findings suggest that provision of in-jail MOUD could improve methadone uptake in the community.

Depression affects over one-third of US military veterans, yet substantial barriers impede access to evidence-based psychotherapy. Internet-delivered cognitive behavioral therapy (iCBT) offers promise for addressing treatment gaps, but no research has examined veteran experiences with fully self-guided digital interventions. This qualitative study explored how veterans with depressive symptoms engaged with Deprexis, a self-guided iCBT program, to inform strategic implementation within Veterans Health Administration (VHA) care systems. Semi-structured interviews were conducted with 18 veterans (mean age 55.2 years, 44% female) who completed on average 7 of 10 iCBT program modules. Reflexive thematic analysis identified patterns across five domains: treatment motivation, therapeutic mechanisms, digital format features, engagement barriers, and implementation recommendations. Veterans valued treatment autonomy, privacy, and accessibility while identifying cognitive decentering and behavioral activation as key therapeutic mechanisms. However, participants articulated a fundamental paradox: iCBT requires self-initiated engagement precisely when depression most impairs motivation. Veterans recommended a stepped-care framework matching intervention intensity to symptom severity, with primary care as the optimal entry point for mild-to-moderate presentations. For moderate severity, veterans suggested minimal external support structures including care coordinator check-ins rather than intensive therapist contact, preserving the resource efficiency enabling scalability. Veterans positioned digital CBT as serving multiple strategic functions within VHA infrastructure: standalone treatment when appropriate, bridge intervention during specialty care waitlists, treatment motivator, or therapy adjunct. Findings provide actionable guidance for deploying evidence-based digital interventions within resource-constrained systems as precision tools addressing specific treatment gaps while preserving intensive services for complex presentations.

Depression is a pervasive global mental health issue, yet access to trained professionals remains severely limited. With the rapid advancement of artificial intelligence (AI), digital tools are increasingly seen as a viable way to address this shortage. However, questions remain about how digital platforms for mental health care can be effectively designed.

This study aimed to investigate, from an end user's (patient's) perspective, the potential use scenarios, desired features, and perceived risks of AI psychotherapists in depression treatment, providing design guidelines for their development.

A grounded theory approach was applied to analyze qualitative responses from 452 individuals recruited via Amazon Mechanical Turk. Data were collected through a scenario-based online survey on AI-assisted depression treatment administered between March 2023 and May 2023. Participants responded to 3 open-ended questions regarding the potential use of AI in treating depression, the characteristics expected from an AI psychotherapist, and the associated perceived risks, along with demographic, control, and contextual measures. The open-ended responses were inductively coded into themes, with intercoder reliability established (Cohen κ=0.80). In addition, variations in themes were further examined across participant profiles, including social stigma, current depression severity, trust in an AI psychotherapist, and privacy awareness.

Participants envisioned AI psychotherapists across 5 primary scenarios: diagnosis, treatment, consultation, self-management, and companionship. Key desired features include professionalism, warmth, precision care, empathy, remote services, active listener, personalization, flexible treatment options, patience, trustworthiness, and basic treatment alternative, while critical concerns include diagnostic inaccuracy, treatment errors, privacy breach, lack of human interaction, technical malfunctions, and lack of emotional engagement. Based on these findings, a general MoSCoW (must have, should have, could have, and won't have) prioritization framework was proposed to serve as a conceptual starting point for future AI system design and empirical validation in mental health care. Notably, feature prioritization varied across user profiles: individuals with higher stigma placed greater emphasis on privacy protection, those with more severe depression prioritized precision care and timely access, low-trust users de-emphasized remote services, and privacy-sensitive individuals showed reduced preference for features requiring extensive data disclosure. These patterns highlight the need for context-sensitive design.

This study provides a patient-centered framework for designing AI psychotherapists and complements the existing literature by highlighting the importance of balancing clinical effectiveness with relational considerations. The findings offer actionable guidelines for designing AI mental health care tools that are aligned with user expectations and sensitive to individual differences.

The transition from adolescence to adulthood (18 to 25 years) is associated with an increased risk of suicidal ideation and behaviors. Suicide-focused cognitive behavioral therapies (CBTs) have been shown to significantly reduce suicidal ideation and behaviors but are not widely available to high-risk individuals. Digital therapeutics could improve access to these treatments.

This study aimed to evaluate the acceptability, safety, and potential efficacy of OTX-202 among transition-age youth (18 to 25 years) receiving mental health care outside an inpatient hospital setting.

In this phase 1 single-arm clinical trial, 59 transition-age youth with recent suicidal ideation or suicide attempts used OTX-202, a smartphone app designed to deliver suicide-focused CBT, concurrently with usual outpatient mental health care. After baseline, eligible patients completed 12 weekly assessments of suicidal ideation, depression, and anxiety.

From baseline to week 12, participants reported statistically significant, large reductions in suicidal ideation (mean difference -5.1, 95% CI -6.5 to -3.7; d=0.95). In total, 3 (5.1%; 95% CI 0%-11.2%) participants reported suicide attempts. Reductions in suicidal ideation and suicide attempt rates were consistent with results from previously published randomized clinical trials of suicide-focused CBTs. Participants rated OTX-202 in the 97th percentile of usability and completed a mean of 9.0 (SD 3.5) of 12 app modules, supporting the app's acceptability. There were no patient deaths, device-related events, or severe adverse events, supporting the app's safety.

Results support the safety, acceptability, and potential efficacy of OTX-202 for reducing suicide risk among transition-age youth.

ClinicalTrials.gov NCT06008132; https://clinicaltrials.gov/study/NCT06008132.

Depression and anxiety frequently emerge during late adolescence and young adulthood; however, many conventional and app-based interventions struggle to sustain engagement. Virtual reality (VR) exergaming, music-based activities, and social interaction each show promise for supporting young people's mental health, but their combined therapeutic value remains insufficiently tested.

This study aims to evaluate the effectiveness of a 6-week VR-based social musical exergame for reducing depressive and anxiety symptoms in young adults. The secondary objectives are to explore whether changes in basic psychological need satisfaction are associated with symptom change and to assess the effects on loneliness, presence, cardiorespiratory fitness, and in-game music-movement synchronization.

This study is a 3-arm, parallel-group randomized controlled trial. A total of 110 participants aged 18 to 25 years with mild to moderate depression or anxiety will be recruited and randomized in a 1:1:1 ratio to (1) a VR social musical exergame, (2) a matched VR solo musical exergame active control, or (3) a waitlist control receiving standardized mental health guidance. Assessments will be completed at baseline, at the postintervention assessment (week 6), and at the 1-month follow-up assessment (week 10). The primary planned comparison is the experimental group vs the active control group.

This study was approved by the ethics committee of Hunan Traditional Chinese Medical College on September 8, 2025 (YXLL202509006) and prospectively registered at ClinicalTrials.gov on March 15, 2026 (NCT07482852). Internal institutional funding had been secured. As of April 2026, the trial status was "not yet recruiting;" no participants had been enrolled, and no data analysis had been conducted. Recruitment is anticipated to begin in May 2026, with primary completion on March 1, 2028, study completion on May 1, 2028, and publication of the primary findings expected in late 2028.

This protocol describes a self-determination theory-informed, multicomponent VR intervention designed to evaluate whether adding a bundled social layer to a matched solo exergame improves short-term mental health outcomes. The trial is expected to provide initial evidence on efficacy, safety, and potential mechanisms while generating hypotheses for future dismantling and longer-term trials.

ClinicalTrials.gov NCT07482852; https://clinicaltrials.gov/ct2/show/NCT07482852.

PRR1-10.2196/83737.

Children with medical complexity (CMC) represent a diverse population who face unique challenges when interacting with the health care system. They are particularly susceptible to disability-based discrimination, or ableism, from health care professionals due to their frequent utilization of health care services. Families and caregivers of CMC also experience psychosocial stressors, mental health challenges, and financial and employment constraints while interfacing with health systems. These factors can negatively impact clinical outcomes and overall quality of life for CMC. It is imperative for health care professionals to understand the impact of disability-based discrimination and social drivers of health on health care outcomes for CMC to advocate for improved care.

Borderline personality disorder (BPD) is highly stigmatized. Stigma, including clinicians' resistance, stigmatizing attitudes, and discriminatory beliefs, could be mitigated by a better knowledge of the disorder. This study evaluates the impact of a one-day training session on stigmatization by health personnel (HP).

This two-center study prospectively included 172 HP who completed a face-to-face interactive training day embodying dialectical and destigmatizing positions. Elements of psychoeducation, emotional dysregulation model and practical tools were presented. Stigma attitudes and open-mindedness were assessed by the Opening Minds Stigma Scale for Health Care Providers self-questionnaire (OMS-HC); and beliefs (feeling of incompetence, pejorative perception of prognosis, guilt) by a custom Beliefs Questionnaire (BQ). Scores before and immediately after the training were compared using Student's paired t-test.

Most HP worked in psychiatry (69%) and had no prior education on BPD (89%). Nurses were most represented (35%), ahead of nursing assistants (22%), psychologists (18%), and psychiatrists (10%). All scores decreased after training (p < 0.001): total OMS-HC (MD ± SD=-4 ± 8), attitude sub-score (2 ± 4), disclosure sub-score (1 ± 4); total BQ (6 ± 9), nurse feeling of incompetence sub-score (4 ± 4) and pejorative perception of prognosis sub-score (-2 ± 3).

A one-day training session reduces HPs' stigmatizing attitudes and beliefs and has a positive impact on knowledge and open-mindedness about BPD patients. Training can lean on education about BPD nature, treatment and prognosis, experience-sharing with practical cases, and testimonies. It would enable compassionate and destigmatizing care. Further research is needed about the clinical impact of BPD training and its wider implementation in mental healthcare settings.

Postpartum post-traumatic stress disorder (PTSD) symptoms are a significant mental health concern. Although obstetric complications are often considered central, growing evidence suggests that women's emotional and subjective responses to childbirth may play a more decisive role in the development of trauma-related symptoms.

To estimate the prevalence of postpartum PTSD symptoms one month after childbirth and to identify the most relevant obstetric, psychological, and psychosocial risk factors, with a particular focus on emotional and dissociative responses.

A prospective observational study was conducted in a high risk maternity hospital between 2021 and 2024. Women completed validated self-report questionnaires one month postpartum, including the PTSD Checklist for DSM-IV (PCL-S), the Peritraumatic Dissociative Experiences Questionnaire (PDEQ), the Peritraumatic Distress Inventory (PDI), and the Edinburgh Postnatal Depression Scale (EPDS). Clinically significant PTSD symptoms were defined by a PCL-S score ≥ 26. Multivariate logistic regression analyses were performed to identify independent predictors.

Among 1,451 women included, 11.8% reported clinically significant PTSD symptoms at one month postpartum. In multivariate analyses, peritraumatic dissociation was the strongest predictor of PTSD symptoms (adjusted odds ratio [aOR] = 2.61), followed by fear of dying during childbirth (aOR = 2.34), stressful life events during pregnancy (aOR = 2.31), and early depressive symptoms (aOR = 1.16 per EPDS point). Obstetric complications, including emergency cesarean section and instrumental delivery, were not significantly associated with PTSD symptoms after adjustment.

Emotional and dissociative responses to childbirth, particularly peritraumatic dissociation, are more strongly associated with postpartum PTSD symptoms than obstetric complications. These findings highlight the importance of early psychological screening using validated tools and support integrated psychoeducation and emotional support into routine perinatal care by somatic healthcare providers.

As third-year medical students transition into high-stakes, high-stress clinical environments like the emergency department (ED), they may experience significant personal trauma. However, little is known about how this trauma is experienced early in their training - specifically during the transition from preclinical to clinical learning environments. This study addresses that gap by exploring third-year medical students' experiences of trauma during the emergency medicine (EM) clerkship through the lens of Trauma-Informed Care (TIC) and identifies workplace factors and intersectional demographics influencing these experiences.

This qualitative study used the critical incident technique to explore emotionally-significant events encountered by third-year medical students immediately after completing the EM clerkship as their first core clerkship at a single academic institution. We conducted a thematic analysis using the Substance Abuse and Mental Health Services Administration's six TIC principles. Data were triangulated with quantitative demographic data, and data saturation was confirmed through constant comparison and reflexive team discussions.

Seventeen students participated, describing 19 critical incidents of trauma. The most common trauma types involved lack of peer support and lack of empowerment or voice. Intersectional factors such as race, gender, and age shaped both the type and nature of trauma. Clinical uncertainty, power differentials, and unprofessional behavior emerged as frequent triggers.

Applying a trauma-informed framework to medical education reveals how structural and interpersonal factors contribute to student trauma when they transition to the clinical learning environment. These findings highlight opportunities for trauma-informed clerkship design and structured support to create safer, more inclusive learning spaces.

Not applicable.