Transcranial direct current stimulation (tDCS) and virtual reality (VR) have emerged as promising non-invasive interventions in treating psychiatric disorders. Despite their individual efficacy in improving symptoms of various psychiatric conditions, the understanding of the combined use of tDCS and VR is limited. This review aims to evaluate the clinical effects and mechanisms of combined tDCS and VR in treating psychiatric disorders.

We conducted a PRISMA 2020-compliant systematic review, searching major databases (PubMed, Web of Science, Scopus, PsycINFO, ScienceDirect, Cochrane Library, Google Scholar, medRxiv and ClinicalTrials.gov) for studies from January 2000 to July 2025 that evaluated combined tDCS-VR in psychiatric populations. Eligible clinical trials were screened, with tDCS/VR parameters and clinical outcomes extracted, and randomized controlled trials appraised using the Cochrane Risk of Bias 2 tool.

Fourteen studies met inclusion criteria: seven reviews and seven empirical trials (five randomized controlled trials, two pilot/feasibility studies) using mainly 1-2 mA prefrontal tDCS paired with disorder-congruent VR. In post-traumatic stress disorder (PTSD) and specific phobias showed short-term symptom reductions, with some PTSD benefits maintained up to 12 months. Evidence for social anxiety and mild cognitive impairment-related depression was limited to single small RCTs with transient or inconsistent improvements. Overall confidence in the evidence is limited by small sample sizes, variable protocols, and risk‑of‑bias concerns.

Although seven small, heterogeneous studies indicate that combined tDCS-VR is feasible and shows preliminary therapeutic promise-most consistently in PTSD and, to a lesser extent, in specific phobias-the overall evidence base remains limited. Mechanistic findings suggesting modulation of medial and ventromedial prefrontal-amygdala circuits are still exploratory. Given substantial methodological heterogeneity, small sample sizes, and risk of bias, tDCS-VR should be regarded as experimental. The larger, well‑designed, disorder‑tailored randomized controlled trials using standardized stimulation/VR protocols, mechanistic outcome measures, and efforts to identify predictors of response are required before routine clinical implementation.

Transitions between inpatient and community care carry a high risk of disengagement or relapse for adults with severe eating disorders. Step Care was developed to address this gap by adapting intensive enhanced cognitive behavioural therapy (CBT-E) for remote, multidisciplinary delivery in patients' homes. The virtual service operates through three pathways, Starting Well, Staying Well, and Working Towards Recovery, and aims to improve engagement, reduce hospitalisation, and prevent relapse.

This paper describes the Step Care service innovation and reports a prospective service evaluation examining its feasibility, acceptability, and short-term outcomes. All patients referred between June 2023 and June 2025 were included. Quantitative outcomes included body mass index (BMI), Eating Disorder Examination Questionnaire (EDE-Q), Clinical Impairment Assessment (CIA), Patient Health Questionnaire-9 (PHQ-9), and Generalised Anxiety Disorder-7 (GAD-7), measured at admission and discharge. Illustrative qualitative feedback from patients, carers, and staff is presented.

Of the 124 referrals, 66 patients commenced treatment (Starting Well, n = 34; Staying Well, n = 22; Working Towards Recovery, n = 10). The mean age was 32.1 years (SD = 12.0), and the mean illness duration was 12.9 years (SD = 11.0); 90% were female and 94% were White British. Completion rates were between 80 and 94% across pathways. In Starting Well, significant improvements were observed in BMI, eating disorder symptoms, psychosocial impairment, and depressive symptoms (all p < 0.01). In Staying Well, BMI was maintained with improved psychosocial functioning (CIA, p = 0.048). In Working Towards Recovery, BMI change was limited, but psychosocial impairment improved (CIA, p = 0.024). Overall, 77% were discharged to community care, 14% required planned admission to hospital, and one required an unplanned admission.

Step Care is a feasible, acceptable, and effective virtual model for delivering intensive CBT-E at key transition points between inpatient and community care. Engagement and completion were high, including among patients with severe and long-standing illness. Short-term improvements were observed in weight and psychosocial functioning, alongside consistently positive feedback from patients, carers, and staff. These findings support further evaluation of long-term outcomes and cost-effectiveness.

Depression and anxiety symptoms in adolescents and young adults represent a significant global public health challenge. Digital health interventions (DHIs) offer potential solutions to supplement traditional mental health services, though the relative efficacy of different types of interventions remains unclear.

This study aims to systematically compare the treatment effects of digital health interventions driven by different mechanisms on depression and anxiety symptoms in this population through a Bayesian network meta-analysis.

A systematic search was conducted in major databases such as PubMed, Embase, and PsycINFO (up to September 2025), including randomized controlled trials (RCTs) targeting depression or anxiety symptoms in individuals aged 12-25 years. Interventions were categorized based on treatment mechanisms into four types: cognitive behavioral therapy-based digital interventions (CBT-DI), third-wave digital therapies (TWDT), general digital mental health support (GDMHS), and technology-enhanced innovative interventions (TEII). The primary outcome measure was the standardized mean difference (SMD), with the cumulative ranking probability assessed using the surface under the cumulative ranking curve (SUCRA).

A total of 18 RCTs involving 5, 821 participants were included. Network meta-analysis indicated that CBT-DI achieved the highest surface under the cumulative ranking curve (SUCRA) values for both depression (79.3%) and anxiety (83.4%). In pairwise comparisons with no intervention controls, CBT-DI demonstrated a statistically significant improvement in anxiety symptoms (SMD = 0.33, 95% CrI: 0.05 to 0.69). However, for depression, the improvement associated with CBT-DI did not reach statistical significance (SMD = 0.44, 95% CrI: -0.02 to 0.91), suggesting that the high ranking probability reflects a potential trend rather than confirmatory evidence of superiority. TWDT and GDMHS demonstrated moderate efficacy for both symptoms, ranking above usual care and no intervention controls. The evidence quality assessment (GRADE) indicated that the primary outcomes were of low to moderate quality.

Digital health interventions, particularly CBT-based interventions (CBT-DI), were associated with statistically significant improvements in anxiety symptoms. For depression, while CBT-DI ranked highest in probability, it did not demonstrate statistical superiority over controls. Given the imprecision in effect estimates, CBT-DI may be considered a potential complementary measure within a stepped-care mental health system. Results should be interpreted with caution due to wide credible intervals, and further high-quality studies are required to confirm these findings.

Suicide represents a major public health challenge globally, with depression, anxiety, and stress constituting well-established risk factors. Spiritual health has emerged as a potentially protective factor against psychological distress, yet its relationship with mental health outcomes in suicide attempters remains inadequately characterized, particularly in Middle Eastern populations where spiritual and religious frameworks play central roles in cultural identity.

This study aimed to investigate the relationship between spiritual health and depression, anxiety, and stress among individuals who attempted suicide in Yasuj, Southwest Iran.

This cross-sectional study was conducted on 136 individuals who attempted suicide and were admitted to Imam Sajjad Hospital in Yasuj, Iran, during 2023-2024. Participants were selected using convenience sampling. Data were collected through face-to-face interviews using a demographic questionnaire, the Depression Anxiety Stress Scale-21 (DASS-21), and the Paloutzian and Ellison Spiritual Health Questionnaire. Data analysis was performed using SPSS version 26, employing descriptive statistics and Spearman correlation coefficients to examine relationships between spiritual health and psychological distress variables across urban and rural subgroups.

The sample consisted predominantly of young adults aged 16-30 years (70.6%), females (55.9%), single individuals (64.0%), and urban residents (76.5%). Drug ingestion was the most common suicide method (94.9%), and 34.5% reported prior suicide attempts. Severe to extremely severe depression was present in 80.9% of participants, with 81.6% experiencing severe to extremely severe stress, and 38.9% reporting severe to extremely severe anxiety. Spiritual health demonstrated significant negative correlations with depression (urban: r = -0.591, p < 0.01; rural: r = -0.544, p = 0.001) and stress (urban: r = -0.602, p < 0.01; rural: r = -0.499, p = 0.004). However, correlations between spiritual health and anxiety were weak and non-significant in both urban (r = -0.186, p = 0.059) and rural areas (r = -0.100, p = 0.585). Strong positive intercorrelations were observed among depression, anxiety, and stress (r = 0.430-0.663, all p < 0.01).

Spiritual health is significantly and inversely associated with depression and stress, but not with anxiety, among suicide attempters in Southwest Iran. These findings suggest that spiritual health may serve as a protective factor against specific dimensions of psychological distress in this high-risk population. The integration of spiritual health assessment and spiritually-informed interventions into comprehensive suicide prevention and post-attempt care protocols may enhance treatment outcomes, particularly for individuals whose cultural and personal identities incorporate spiritual dimensions. Future longitudinal research is needed to establish causal relationships and evaluate the efficacy of spiritually-integrated therapeutic interventions for reducing psychological distress and preventing suicide reattempts.

Not applicable.

Effort-based decision-making (EBDM) impairments predict negative symptoms across multiple psychiatric diagnoses. However, it is unclear whether equifinality is present and different disorders reach the same clinical endpoint of negative symptoms via different mechanistic EBDM processes. This study used computational modeling to isolate processes underlying EBDM in a large severe mental illness-spectrum sample. The Effort Expenditure for Rewards Task, negative symptom measures, and neuropsychological tests were administered to 920 participants: schizophrenia (SZ; n = 147), first-episode psychosis (FEP; n = 54), bipolar disorder (n = 53), depressive disorder (n = 37), clinical high-risk for psychosis (CHR; n = 231), other clinical (n = 99), and healthy control groups (HC; n = 299). Computational modeling identified whether participants' EBDM behavior was best fit by models indexing full or partial subjective value (use reward magnitude and/or probability) or bias (failure to use reward magnitude and probability). Best fitting models significantly differed across diagnostic groups. SZ and FEP were best fit by the bias model and less likely to use reward magnitude and probability to guide EBDM. The CHR, other clinical, depressive disorder, and HC groups were best fit by the full subjective value model and were more likely to use reward magnitude and probability, while the bipolar disorder group's behavior was more variable. Across groups, participants best fit by the bias model had the greatest negative symptoms and cognitive impairments. Results indicate mood and psychosis-spectrum disorders differentially approach EBDM. Equifinality in the pathway to negative symptoms was not supported; those with difficulty utilizing reward and probability information had the greatest negative symptoms, independent of diagnosis.

Pragmatic language impairments-difficulties using language effectively in social contexts-are common in adults suffering from severe mental illnesses (SMIs) such as schizophrenia spectrum disorders (SSD), major depressive disorder (MDD), and bipolar disorder (BD). These impairments hinder social functioning and recovery but have been explored most widely using comprehension tasks, with pragmatic production being poorly described. We undertook a systematic review and meta-analysis of studies assessing expressive pragmatic language in adults with SMIs versus healthy controls. 18 items were tested, including Coherence, Cohesion, Gricean maxims, figurative language, Prosody, and Turn-Taking. The searches were PRISMA-compliant and were conducted in PubMed and Scopus. 51 studies were included; 28 were meta-analyzed. Results showed significant impairments in Cooperativity, Anaphora and Cohesion, moderate impairments in Coherence, and low impairments in Metaphor. No significant moderator was detected. Our results emphasize the need for standardized pragmatic testing and intervention for language production in clinical settings.

Aggression and agitation are among the most distressing and treatment-resistant behavioral and psychological symptoms of dementia (BPSD), and conventional pharmacological or behavioral interventions often provide limited benefit and carry substantial risks in frail older adults. We conducted a systematic review in accordance with PRISMA guidelines, searching PubMed, EMBASE and the Cochrane Library through September 24, 2025 for clinical studies of electroconvulsive therapy (ECT) for agitation and/or aggression in dementia, including case reports, case series, observational cohorts, chart reviews and randomized trial protocols. Data on patient characteristics, ECT parameters, outcomes, adverse events and consent procedures were extracted, and exploratory random-effects pooling of clinical response rates was performed. Thirteen studies including 206 patients met inclusion criteria. Across studies, most patients showed clinically relevant improvement, with reported response rates typically between 70% and 90%; exploratory meta-analytic pooling yielded a clinical response proportion of 77.7% confidence interval CI (95% CI 71.0%-83.3%), which remained stable in sensitivity analyses (n ≥ 5: 81.2%, 95% CI 71.7%-88.0%). Improvement usually emerged within 2-4 treatments (median = 3 sessions), and reductions in agitation and aggression were supported by validated instruments such as the Cohen-Mansfield Agitation Inventory (CMAI) and Pittsburgh Agitation Scale (PAS). ECT was generally well tolerated, with mostly mild and transient adverse effects and no reported treatment-related deaths or persistent severe complications. Available evidence suggests that ECT may provide a rapid, effective and relatively safe last-resort option for otherwise refractory aggression and agitation in dementia, but confirmatory prospective and ethically informed controlled studies are needed.

Background and Purpose: This article aimed to develop and psychometrically validate the Persian Student Nurse Stress Index (SNSI). The SNSI is a culturally tailored tool that assesses stress among Iranian nursing students. It captures unique sociocultural stressors that are rooted in Iran's collectivist and Islamic context. The SNSI is applicable in other global collectivist settings, such as India, Pakistan, and Indonesia, to inform evidence-based interventions for nursing education. Methods: The SNSI was translated into Persian using a forward-backward translation process. A cross-sectional study was conducted with 408 undergraduate and graduate nursing students from four Iranian universities who were randomly sampled from March 2020 to June 2022. The sample was divided (n = 208 for exploratory factor analysis [EFA], n = 200 for confirmatory factor analysis [CFA]) to ensure robust psychometric validation through separate exploratory and confirmatory analyses. Data were collected using both paper-based and online questionnaires to accommodate student preferences and ensure accessibility. The psychometric evaluation included content validity (scale-level content validity index [S-CVI]), EFA (n = 208), CFA (n = 200), Cronbach's alpha, and test-retest reliability (intraclass correlation coefficient [ICC]). Results: The Persian SNSI comprises 19 items across three factors: expectations, communication, and health (11 items, explaining 38.2% of the variance); academic topics (6 items, explaining 18.6% of the variance); and restrictions on free time (2 items, explaining 8.6% of the variance). These factors explain 65.4% of the total variance. The S-CVI was .88. EFA showed a Kaiser-Meyer-Olkin value of .90 (p < .001). CFA confirmed an acceptable fit (root-mean-square error of approximation = .11, comparative fit index = .93, and incremental fit index = .93). Cronbach's alpha was .86, and the ICC was .88. The mean stress score was 54.86 (SD = 16.78), with interpersonal stressors being the most prominent. Conclusions: The Persian SNSI is a valid and reliable tool for assessing stress in Iranian nursing students. It could inform evidence-based interventions, such as counseling and curriculum reforms, to enhance student mental health and academic success. The tool's scalability makes it a transformative model for nursing education in collectivist societies.

A 73-year-old man developed subacute cognitive impairment, status epilepticus and reduced level of consciousness requiring mechanical ventilation. An MR scan of the brain showed multifocal inflammatory lesions, but with normal cerebrospinal fluid (CSF); blood results showed positive antinuclear antibody (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies (Abs), but normal complement and urine analysis. Commercial kit for cell-surface antineuronal antibodies, including anti-NMDAR (anti-N-Methyl-D-Aspartate Receptor antibody), anti-LGI1 (anti-Leucine-Rich Glioma-Inactivated 1 antibody), anti-CASPR2 (anti-Contactin-Associated Protein-Like 2 antibody), anti-GABA-BR (anti-Gamma-Aminobutyric Acid Type B Receptor antibody), anti-AMPAR (anti-α-Amino-3-Hydroxy-5-Methyl-4-Isoxazolepropionic Acid Receptor antibody) and anti-DPPX (anti-Dipeptidyl-Peptidase-Like Protein-6 antibody), was negative in serum and CSF. We gave methylprednisolone, plasma exchange, rituximab and cyclophosphamide. However, despite initial improvement, he had five relapses. We reassessed the diagnosis and identified a thymoma; also, research laboratory testing with tissue-based and cell-based assays identified anti-GABA-AR Abs. He improved following thymectomy and with tocilizumab. This case underscores the complexity and varied presentations of anti-GABA-AR encephalitis with thymoma, emphasising the importance of comprehensive antibody testing in making this challenging diagnosis.